Citation
Effect of Bug-in-the-Ear Feedback as an Intervention to Promote Attachment Behaviors in the Adolescent Mother/Infant Dyad

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Title:
Effect of Bug-in-the-Ear Feedback as an Intervention to Promote Attachment Behaviors in the Adolescent Mother/Infant Dyad
Creator:
ARHIN, AFUA OTTIE
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2008

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Subjects / Keywords:
Adolescents ( jstor )
Attachment behavior ( jstor )
Child psychology ( jstor )
Dyadic relations ( jstor )
Infants ( jstor )
Learning ( jstor )
Mothers ( jstor )
Nursing ( jstor )
Parent training ( jstor )
Parents ( jstor )
City of Indian Rocks Beach ( local )

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University of Florida
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Full Text












EFFECT OF BUG-IN-THE-EAR-FEEDBACK AS AN INTERVENTION TO
PROMOTE ATTACHMENT BEHAVIORS IN THE ADOLESCENT
MOTHER/INFANT DYAD















By

AFUA OTTIE ARHIN


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


2005


































This document is dedicated to my children, Kofi and Stephanie.















ACKNOWLEDGMENTS

Endeavors such as this study are most often aided in both direct and subtle ways by

numerous people. It is my opportunity here to give thanks to those who have made this

dissertation a rewarding, educational experience. Unfortunately, written words may not

reflect the magnitude of the debt of thanks which is owed each person.

My thanks begin with my parents, Mr. Ottie and the deceased Mrs. Grace Ottie, to

whom can be attributed much of my interest in learning.

The encouragement given by Dr. Jennifer Elder shall not be forgotten. It will in fact

be difficult to ever repay this lady, friend and scholar for her investment in my personal

development. The same is true for Dr. Jon Bailey for his tutoring, encouragement and

thoughtful critique of this manuscript.

I would like to thank Dr. Bruce Thyer for his encouragement and tireless efforts

especially in having me successfully coauthor with him my very first book chapter. I

would also like to thank Dr. Terry Mills for his persistence and guidance in helping me

with manuscript development and publication. I would like to express my gratitude to Dr.

Sharleen Simpson for her invaluable feedback and support.

The mothers who participated in this study and their families must most certainly

be thanked for their cooperation. The staff of Capital Area and Gadsden County Healthy

Start must be thanked for their cooperation and support in my recruiting efforts. I would

also like to thank Florida Nurses' Foundation for the dissertation grant award that partly

funded this study.









And in the end, I suppose the single greatest thanks goes to my husband, Kwame,

and my children, Kofi and Stephanie. I am indebted to them for their patience, love and

encouragement and hope they see in this work, parts of their positive influence.















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ......... .................................................................................... iii

LIST OF TABLES ............. ................................ ... ................ viii

LIST OF FIGURES ......... ........................................... ............ ix

A B STR A C T ................................................. ..................................... .. x

CHAPTER

1 A TTA C H M E N T TH E O R Y .................................................................. ....... ..... 1

D defining A ttachm ent ......................... .... ......................... ....... ..... .............. .. 1
Attachm ent in A adolescent M others ........................................ ......................... 2
E theological T theory ..................... ...... .... ...... ...... ........ ........ .............. ....... .. .2
Function of Imprinting and Innate Signaling in Parent-Infant Bonding .............3
D defining A ffectional B onds ........................................................................... 3
Studies of Affectional Mother-Infant Bonds in Adolescents ..............................4
Behavioral Approach and Learned Helplessness ........................................ ..............5
Defining the Dependency and Drive Reduction Model .......................................5
Importance of Early Relationship Experiences ..............................................5
L earned H helplessness ........... ... ..... ................................. .... .... ........ .. .. .6
Interventions to Counter the Development of Learned Helplessness ..................7
F am ily Stress M odel ................ ........................................ ........ ........ ... .........
Defining the Family Stress M odel.......... ............. ................... .............. 8
A B CX Theory of Fam ily Stress ..........................................................................
Applying Family Stress Theory to Adolescent Mothers and Infants ..................9
Parent Training Paradigm ............. ......................... ... ................ ............... 10
Contribution of Self -Efficacy and Social Learning Theory .....................................10
Incorporation of Behavioral Principles in Parent Training ..............................12
Nursing Theory and the Nursing Meta-paradigm....................................................13
King's Theory of Goal Attainment................. ............. ..... ............... 13
Congruence of King's Theory with Bandura's Self Efficacy Theory.................14
Implications for Nursing Practice......... .. ................................. ...... ......... 15
S u m m a ry ....................................................... .............. ................ 1 5
State ent of Purpose ....................................................... ................. 17









2 REVIEW OF THE LITERATURE ......................................... ...............18

Importance of Mother Infant Interaction ............... ... .... .... ................18
Importance of interventions in adolescent mothers............................. ....... 18
Review of Intervention Literature in the Adolescent /Mother Infant Dyad ........19
Bug-in-the-ear feedback (BITE)................................... ....................................21
Single Subject Design ............................................ .. ......... ............ 22

3 M E T H O D O L O G Y ............................................................................ ................... 24

P participants and Setting ........................................... .................. ............... 24
P ilo t T e stin g ................................................................................................... 2 5
P a rtic ip a n t 1 ................................................................................................... 2 5
In fa n t 1 ........................................................................................................... 2 6
P a rtic ip a n t 2 ................................................................................................... 2 6
In fa n t 2 ........................................................................................................... 2 6
P a rtic ip a n t 3 ................................................................................................... 2 6
In fa n t 3 ........................................................................................................... 2 7
P ro c e d u re s ..................................................................................................... 2 7
Experimental Procedure .............................................. ...............27
Baseline Phase ............................................. ................. 28
Intervention ....................................... ............ ........ ...............29
Instruments for Evaluating Dependent Variables............................... 29
N C A S T .....................................................................................................2 9
O operational D definitions ............................................................3 1
In dep en dent V ariab les ................................................................................... 3 1
Inter-observer Reliability .......................................................................33
D ata A n a ly sis ........................................................................................................ 3 4

4 R E S U L T S .............................................................................3 6

F in d in g s ................................................................3 6
S en sitiv ity to C u es ...............................................................36
P a rtic ip a n t 1 ................................................................................................... 3 7
P participant 2 ............................................................................................... 38
P a rtic ip a n t 3 ................................................................................................... 3 8
Social-Emotional Growth Fostering .................................................................. 38
P a rtic ip a n t 1 ................................................................................................... 3 9
P participant 2 ............................................................................................... 40
P a rtic ip a n t 3 ................................................................................................... 4 0
C ognitive G row th F ostering ................................................................................. 43
P a rtic ip a n t 1 ................................................................................................... 4 3
P participant 2 ............................................................................................... 43
P a rtic ip a n t 3 ................................................................................................... 4 4
C h ild 's C clarity of C u es ......................................................................................... 4 4
C hild's R response to M other ................................................................................. 47
In fa n t 1 ........................................................................................................... 4 7









In fa n t 2 ........................................................................................................... 4 9
In fa n t 3 ........................................................................................................... 4 9
Summary of Findings ..................................... .... .... ...... ...............5 1

5 D IS C U S S IO N ...............................................................................................5 3

O v erview .................. .........................................................................53
Participant Characteristics and Behaviors ...................................... ............... 54
P a re n t T ra in in g ..................................................................................................... 5 6
R recruiting for the Stu dy ...................................................................... .................. 57
Limitations of the Study and Recommendations................................................... 58
Implications for Nursing Practice..................................................................... 59

APPENDIX INFORMED CONSENT ........................................ ........................ 62

L IST O F R E FE R E N C E S ..................................................................... ..... ...................70

B IO G R A PH IC A L SK E TCH ..................................................................... ..................77
















LIST OF TABLES


Table page

3-1 Videotaping Schedule of Participants ........................................... ............... 28

3-2 Inter-ob server R liability .............................................................. .....................34

4-1 Sensitivity to Cues: Frequency of Infant's Head Higher than Mother's Hips .........37

4-2 Sensitivity to Cues: Frequency of Mother Maintaining Trunk to Trunk Position ...37

4-3 Social- Emotional Growth Fostering. Frequency of Mother Maintaining Enface
P o sitio n ....................................................................... 3 9

4-4 Child's Clarity of Cues-Builds up Tension ..............................................44

4-5 Child's Clarity of Cues-Decrease in Tension................................ ............... 45
















LIST OF FIGURES


Figure page

4-1 Frequency of mother's comments on infant's hunger during baseline and
intervention phases ......... .... ............. ............. ................. 41

4-2 Frequency of mother's smiles and use of positive statements during baseline and
intervention phases ........................... ............................. 42

4-3 Frequency of mothers exhibiting cognitive growth behaviors during baseline and
intervention phases ........................... .................... .. ..... ... 46

4-4 Infant 1 Frequency of infant looking in mother's direction................................47

4-5 Relationship between Infant 1 looking in mother's direction and target behaviors
during baseline and intervention phases........................................ ............... 48

4-6 Infant 2 Frequency of infant looking in mother's direction................................49

4-7 Relationship between Infant 2 looking in mother's direction and target behaviors
during baseline and intervention phases........................................ ............... 50

4-8 Infant 3 Frequency of infant looking in mother's direction........................ 51

4-9 Relationship between Infant 3 looking in mother's direction and target behaviors
during baseline and intervention phases........................................ ............... 52














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

EFFECT OF BUG-IN-THE-EAR-FEEDBACK AS AN INTERVENTION TO
PROMOTE ATTACHMENT BEHAVIORS IN THE ADOLESCENT
MOTHER/INFANT DYAD

By

Afua Ottie Arhin

December 2005

Chair: Jennifer Elder
Major Department: Nursing

Background: Previous studies have shown that compared with adult mothers,

adolescent mothers are less verbally and emotionally responsive, show less positive

affect, and have less intense emotional and behavioral attachment interactions with their

children. These less than optimal adolescent mother/infant attachment interactions have

been found to affect the child's healthy growth and development.

Objectives: The study aimed to identify and characterize the frequency of

attachment behaviors exhibited in the infant/adolescent mother dyad and obtain a

baseline of the frequency of the interaction on the NCAST Feeding Scale. The second

aim was to implement an individualized bug-in-the-ear feedback parent training model to

improve the frequency and quality of infant-mother interaction and assess its efficacy

using the NCAST Feeding Scale. The third aim was to compare mother/infant attachment

behavior frequencies pre and post training.









Methods: A non-concurrent multiple baseline design across three participants was

used. Baseline videotaping was done at the home of three 15-year old African American

mothers as they formula fed their infants who were between the ages of 11/2 to 51/2-

months. The baseline sessions were repeated until a stable baseline of interaction

behaviors was achieved. The individualized intervention using a bug-in-the-ear feedback

was instituted based on the occurrence or non-occurrence of target behaviors that were

identified using the NCAST Feeding Scale.

Results: The baseline phase of the study clearly identified low frequency and non-

occurrence of attachment behaviors of the verbal/communication type. After the

intervention was instituted in the second phase of the study there were positive effects in

the mother's behaviors which in turn positively impacted infant behavior. This was

particularly notable in the area of the child responding to the mother.

Conclusion: Findings from this study extend and strengthen previous research in

this area that has shown that adolescent mothers are less verbal to their infants. Although

the intervention was successful in this study, it is important to indicate that the bug-in-

the-ear feedback intervention was a labor intensive approach in changing mother/infant

interaction behaviors. Thus, further nursing research is warranted on exploring the best

approaches in changing these rather complex and difficult behaviors.














CHAPTER 1
ATTACHMENT THEORY

Defining Attachment

Attachment in humans refers to an affectional tie that one person forms with

another specific individual. The first individual is most likely the mother and attachment

tends to endure (Ainsworth, 1989). Through theoretical developments of John Bowlby

and Mary Ainsworth, a rich knowledge base of attachment has emerged which

emphasizes the importance of the infant's security. According to Bowlby (1982), the

pathway followed by each developing individual and the extent to which he or she

becomes resilient to stressful life events is determined to a very significant degree by the

pattern of attachment developed during the early years. Subsequent studies have

confirmed that a mother's attachment to her infant is a major contributor to the child's

healthy growth and development (Ainsworth, 1989).

Attachment in Bowlby's framework is the bio-behavioral process that leads from

distress to solace, from real or perceived danger to "felt safety." It can be defined as

proximity seeking, comfort-seeking, and security-seeking in situations of real or

perceived threat of danger. The ability of the mother and the infant to communicate is a

delicate yet necessary element in a good relationship. Mothers use various sensorimotor

means to interact with an infant. Touch and visual contact are the most powerful means

of communicating with an infant (Brazelton & Cramer, 1990). Crying, smiling, grasping,

reaching out and establishing visual contact are among the attachment behaviors that

infants display to maintain proximity with their parents and express their needs.









Attachment in Adolescent Mothers

Adolescent mothers may be at high risk for negative parent child interactions.

Studies have shown that compared with adult mothers, adolescent mothers are less

verbally and emotionally responsive, show less positive affect, and have less intense

emotional and behavioral involvement with their children (Christopher, Bauman &

Veness- Meehan, 1999). There is much evidence in the literature suggesting that

adolescent mothers are at risk for adverse psychological and behavioral problems that can

affect the mother's life course as well as the infant's health and development. Adolescent

mothers have displayed higher levels of parenting stress and are less responsive and less

sensitive in interactions with their infants than adult mothers (Passino et al., 1993).

Further, adolescent mothers may be less competent to parent in terms of their

emotional development, parenting experience, and parenting skills (Furstenberg, Brooks-

Gunn, Chase-Lansdale, 1989). Consequently, children of adolescent mothers have been

found to suffer more physical, intellectual and emotional difficulties. Disturbed

attachments have been implicated in the development of dysfunctional parent-child

relationships (Koniak-Griffin, 1988) and other negative outcomes. Since adolescents are

responsible for almost 500,000 births in the United States annually (Ventura, Martin,

Curtin & Matthews, 1998), and there appears to be such an ominous impact of this

phenomenon on the infant and his or her long term outcome, it is imperative that this

public health problem is closely analyzed.

Ethological Theory

Ethology is concerned with the adaptive, or survival, value of behavior and its

evolutionary history (Hinde, 1988). This theoretical orientation was first applied to

research on children in the 1960s, but has become more influential in recent years. The









origins of ethology can be traced to the work of Darwin. Its modern foundations were laid

by two European zoologists, Lorenz and Tinbergen (Dewsbury, 1992). Watching the

behaviors of animal species in their natural habitats, Lorenz and Tinbergen observed

behavioral patterns that promote survival. The most well known of these is imprinting,

the early following behavior of baby geese that ensures that the young will stay close to

the mother, be fed, and protected from danger. From the ethological perspective,

attachment is an innate human survival mechanism.

Function of Imprinting and Innate Signaling in Parent-Infant Bonding

Bowlby (1969), who first applied this idea to the infant-caregiver bond, was

inspired by Lorenz's studies of geese imprinting. He believed that the human baby, like

the young of most animal species, is equipped with a set of built-in behaviors that helps

keep the parent nearby, increasing the chances that the infant will be protected from

danger. Contact with the parent also ensures that the baby will be fed, but Bowlby was

careful to point out that feeding is not the basis of attachment.

According to Bowlby, the infant's relationship to the parent begins as a set of innate

signals that call the adult to the baby's side. As time passes, a true affectionate bond

develops, which is supported by new cognitive and emotional capacities as well as a

history of consistent and sensitive, responsive care by the parent. Out of this experience,

children form an enduring affectional bond with their caregivers. This enables the child to

use this attachment figure as a secure base across time and distance.

Defining Affectional Bonds

Affectional bonds are formed as a result of reinforcing interactions with the

attachment figure and the child. Emotional life is seen as dependent on the formation,

maintenance, disruption or renewal of attachment relationships. Consequently, the









psychology and psychopathology of emotion are deemed to be largely the psychology

and psychopathology of affectional bonds. The fundamental assumption in attachment

research on human infants is that sensitive responding by the parent to the infant's needs

results in an infant who demonstrates secure attachment, while lack of such sensitive

responding results in insecure attachment (Lamb, Thompson, Gardner & Charnov, 1985).

Theorists have postulated several varieties of insecure attachment. Ainsworth et al.

originally proposed two: avoidant, and resistant also called ambivalent (Ainsworth,

Blehar, Waters, & Wall, 1978).

The work of Klaus and Kennell (1976) on maternal bonding had a great impact on

nursing practice. Maternity and neonatal hospital settings were modified to promote early

and extensive contact between mothers and their newborn infants in order to promote

attachment. However, this hypothesis of a critical period has been challenged by other

studies (Gay, 1981; Rubin, 1984). Given the contradictory findings early contact cannot

be used as the sole marker on which mother/infant attachment is evaluated, even though

beneficial effects have been reported. Attachment can also be evaluated in periods past

the immediate postpartum period.

Studies of Affectional Mother-Infant Bonds in Adolescents

It has been suggested in the literature that adolescent mothers by virtue of their

immaturity have difficulty establishing optimal interactions with their infants. In a study

conducted in the University of Pittsburgh, thirty-eight full-term, first-born infants of

adolescent mothers were assessed at six months of age in a standardized laboratory

setting using a modified Ainsworth Strange Situation procedure (Broussard, 1995). The

attachment security rate within this sample was 23.7%. Attachment security problems

were attributed to faulty interaction patterns between the adolescent mother and infant.









Another study conducted through Oklahoma State University compared adolescent

mothers' and older mothers' interaction patterns with their six-month-old infants. During

feeding, the adolescent mothers demonstrated less expressiveness, less positive attitude,

less delight, less positive regard, fewer vocalizations and a lower quality of vocalizations

than non adolescent mothers. During play, the adolescent mothers demonstrated less

inventiveness, patience and positive attitude (Culp, Culp, Osofsky & Osofsky, 1991).

Behavioral Approach and Learned Helplessness

Defining the Dependency and Drive Reduction Model

The behavioral approach of attachment is based on the dependency and drive

reduction model. Dependency is viewed as an acquired drive originating because the

helpless infant is dependant on his mother for gratification of his basic physiologic needs

(Sroufe, Duggal, Weinfield & Carlson, 2000). The crying and other behaviors

characteristic of the infant are reinforced through his/her mother's nurturing actions,

making them more likely to occur again. The stimulus provided by the mother's face and

presence signals impending gratification. This is how the infant acquires a drive to be

close to his/her mother and seek her attention. This dependency drive is eventually

generalized to other people in the child's life.

By the second half-year, an infant exhibits purposeful goal directed behavior.

(Sroufe, Duggal, Weinfield & Carlson, 2000). Infants behave in order to elicit a particular

response from the mother such as raising arms to indicate a desire to be picked up. At this

point, the infant actively participates in the regulation process.

Importance of Early Relationship Experiences

Early relationship experiences are vital because they are the first models of patterns

of self-regulation. Infants generalize to what they experience. If they learn that they can









turn to others when in need and get responses they will believe in their own effectiveness

in maintaining regulation. Also because their needs are routinely met, they will believe in

their self worth .A sense of personal effectiveness follows from routinely having one's

actions achieve their purposes. These positive expectations towards others as well as self-

confidence are logical outcomes of experiencing routinely responsive care. This provides

an important foundation for later self-regulation (Sroufe, Duggal, Weinfield & Carlson,

2000).

Learned Helplessness

When care is chaotic, inconsistent or rejecting such as in high- risk mothers

including adolescents, an anxious attachment relationship may evolve. In the face of

inconsistency, the infant may maximize the expression of attachment behaviors, emitting

high intensity signals such as inconsolable crying, or alternatively may learn to cut off

expression or attachment behaviors (Sroufe, Duggal, Weinfield & Carlson, 2000).

This strategy is consistent with the theory of learned helplessness.

Learned helplessness occurs when a person cannot control outcomes. Mark (1983)

defines this as an adaptive response to situational demands. It is further explained by

Seligman (1975), who developed the concept as the reduction of efforts and motivation

after an individual's efforts have little or no impact on the outcome. In the most extreme

form of this condition, the person does not try to initiate anything. The effects of learned

helplessness are experienced in one or more of the following domains: motivational,

affective and cognitive (Abramson, Seligman & Teasdale, 1978).

In a recent study examining the concept of learned helplessness, prenatal

characteristics including cognitive readiness for parenting, intelligence and personal

adjustment of 121 adolescent mothers were examined and correlated with the behavior









outcomes of their children (Sommers et al., 2000). The findings indicated that by age 3,

many of the children were at high risk for atypical and perhaps dysfunctional

development. Less than 30% of the sample which was generally healthy at birth showed

normal cognitive development, emotional functioning and adaptive behavior at 3 years of

age. The learned helplessness model provides a possible explanation for the behaviors

that are seen in these children. It may be that for children who have rarely been

successful with interacting with their mothers, withdrawal is an effective self defense

mechanism protecting them from greater failure.

Interventions to Counter the Development of Learned Helplessness

On a positive note, it may be possible that many learned helplessnes. Risk factors

can be reduced by instituting intervention programs to facilitate the development of an

early, successful attachment bond between the adolescent mother and her infant. One

example of such an intervention is that of Field (1998) who investigated 40 full term 1 to

3 month old infants born to depressed adolescent mothers who were low socioeconomic

status and single parents. The infants were given 15 minutes of either massage or rocking

for 2 days per week for a 6-week period. A comparison of infants in the massage therapy

group with infants in a rocking control group showed that the massaged infants spent

more time in active alert and awake states and cried less. Over the 6-week period, the

massaged infants gained more weight and showed greater improvement on emotionality,

sociability and soothability. There were also decreases in stress hormones. These results

suggest that actively engaging infants may have a positive effect on the overall well being

of the child.









Family Stress Model

Defining the Family Stress Model

Another theoretical approach that could be used in explaining less than optimal

attachment in the adolescent mother-infant dyad is the family stress theory. Family stress

theory postulates that acute stressors when accumulated could lead to family crises,

including physical, emotional, or relational crises (McDonald, 1999).

ABCX Theory of Family Stress

Hill's (1971) theory of family stress was formulated after the Great Depression,

based on extensive observations of families who survived contrasted with those whose

families did not. As Hill interviewed families who had lost their jobs and were existing

in extreme poverty, he looked for factors which contributed to family survival of these

circumstances. From these qualitative data, Hill theorized that there are two complex

variables that act to buffer the family from acute stressors and reduce the direct

correlation between multiple stressors and family crisis. These were formulated into what

he called his ABCX theory of family stress.

The "A" variable is the stressful event; the "B" variable refers to the complex of

internal and external family resources and social support available to the family, i.e., the

social connectedness within the family, as well as social connectedness outside the

family. Hill theorized that social isolation would significantly increase the impact of the

multiple stresses on the family functioning. In contrast, positive social supports would

minimize the impact. Hill's "C" variable, the perception factor, was the second predictor

of the extensiveness of the impact of stress on the family.









Applying Family Stress Theory to Adolescent Mothers and Infants

Applied to the adolescent mother/infant dyad, this theory suggests that families

with poor resources, who perceive the pregnancy as a crisis, may have poor mother-infant

interactions and function at lower levels. After a period of reorganization, families with

higher cognitive appraisals and support are able to regroup and operate at a higher than

baseline level while families with poor support and lower cognitive appraisals continue to

function at a lower level.

Family stress theory, when applied to attachment behaviors of the adolescent

mother-infant dyad, clearly underscores the importance of social support and how nursing

could play a vital role in promoting the well being of the adolescent mother-infant dyad.

This could be in the form of providing social support throughout the pregnancy or the

initiation of prevention programs. There are documented studies that have shown the

clear benefits of early prenatal involvement by community nurses in high risk mothers

(Darmstadt, 1990).

Adopting the attachment paradigm as a framework for early intervention and

primary prevention in the adolescent mother-infant dyad has tremendous nursing practice

implications. The literature suggests that the experimenter-mother interaction provides

emotional support for the mothers participating in intervention programs and that such

support is an important variable enhancing the quality of maternal behavior (Kelly &

Barnard, 2000). Further, several researchers have suggested that professionals'

intervention behaviors could serve as models for mother-child interaction behaviors.

However, there is little information on the best conditions of intervention and its effect on

later development. It is evident from the preceding theoretical review that effective

mother-infant interaction may be compromised in the adolescent mother/infant dyad,









leading to negative outcomes in the child. It is therefore imperative that effective

interventions such as parent training are established to help improve the long-term

outcomes of these children.

Parent Training Paradigm

The birth of a child is a very emotional time for mothers who may experience a

wide range of emotions from joy and excitement to frustration and disappointment. While

such emotions come naturally, knowledge and skills related to parenting are less natural.

Most studies suggest that behavioral parent training is an effective early intervention

strategy for families with infants (Breismeister & Schaefer, 1997). Important components

of early intervention are teaching mothers to read and interpret infant cues, effectively

manage the infant's behavior and to promote positive mother-child interactions. This type

of intervention may ultimately prevent negative outcomes in the child.

Contribution of Self -Efficacy and Social Learning Theory

Behaviorally focused parent training is a generic term that refers to teaching parents

how to become therapeutic change agents for their children (Hoffman, 1998). Parents are

provided the appropriate knowledge, skills, and incentives to initiate coping efforts and

persistence in the face of difficulty in relating to their child. Parent training is designed

to offer parents new resources for enhancing their parenting skills (Breismeister &

Schaefer, 1997). One of the benefits of the parent training approach is that it allows

parents to develop a well established sense of mastery and confidence in their parenting

skills.

This concept of achieving mastery and confidence is consistent with Bandura's

theory of self efficacy. Perceived self-efficacy is defined as people's beliefs about their

capabilities to produce designated levels of performance that exercise influence over









events that affect their lives (Bandura, 1995). A strong sense of efficacy enhances human

accomplishment and personal well-being in many ways. People with high assurance in

their capabilities approach difficult tasks as challenges to be mastered rather than as

threats to be avoided. Such an efficacious outlook fosters intrinsic interest and deep

engrossment in activities. Such individuals set themselves challenging goals and maintain

strong commitment to them. They heighten and sustain their efforts in the face of failure.

These individuals quickly recover their sense of efficacy after failures or setbacks. They

attribute failure to insufficient effort or deficient knowledge and skills which are

acquirable. They approach threatening situations with assurance that they can exercise

control over them. Such an efficacious outlook produces personal accomplishments,

reduces stress and lowers vulnerability to depression (Bandura, 1986).

The self-efficacy literature suggests that efficacious expectation alone will not

produce the desired performance if the component capabilities are lacking (Bandura,

1977). People also require the appropriate knowledge, tools, skills, and incentives that

can be acquired through learning.

Social learning theory has its roots in the behaviorist notion of human behavior as

being determined by learning, particularly as shaped by reinforcement in the form of

rewards or punishment. This theory is based on early research in behaviorism conducted

by Ivan Pavlov, John Watson, and B. F. Skinner. One of the key premises of social

learning theory is that the child's behavior, whether adaptive or maladaptive, desirable or

undesirable, is in part a product of the child's history and present interactions with people

and circumstances that impact on the child (Breismeister & Shaefer, 1998).









In the context of promoting attachment behaviors and for an interaction between a

mother and child to be effective, the infant and mother must give clear cues to each other.

The mother must know how to respond to the infant's cues and the infant must respond to

the mother's cues and the environment must facilitate the interaction that occurs. The

interaction becomes a cyclical learning event that either reinforces the behavior that

occurs or facilitates its termination (Barnard, Morisset & Spieker, 1993).

Incorporation of Behavioral Principles in Parent Training

Many procedures in parent training can be derived from the general behavioral

principles. Early research was patterned in many ways after the style of research

developed by Skinner (1957). A fundamental feature of the methodology is the detailed

analysis of the behavior of an individual and some type of intervention procedure brought

into contact with the target behavior. The specific behavioral parent training procedure is

determined by specific problems and needs (Breismeister & Shaeffer, 1997). In the

context of the young mother and her infant, providing the appropriate knowledge and

skills through parent training may enhance the reciprocal interacting abilities of the dyad.

Because the innate characteristics of the child are difficult or impossible to alter,

interventions practiced to date for promoting mother child attachment have focused on

the mother's behaviors. The goals of these interventions have been to increase

competence of the mother in interpreting and responding to the infant's communication

cues by alleviating distress and promoting growth-fostering behaviors (Barnard, Morisset

& Spieker, 1993).

The specific parent-training that will be used in this study consists of prompting

and cueing (antecedent stimulus variables) by the investigator through a wireless

earphone. This training approach relies heavily on Skinner's stimulus-response model.









A number of published studies have shown the clear benefits of early intervention

programs in facilitating the development of early attachment between mother and child.

Meyer and Anderson (1999) reported on an individualized family based intervention that

significantly reduced maternal stress and depression and enhanced mother-infant feeding

interactions. Barnett (1995) identified that the most promising parent training programs

operate at the level of preventative and early interventions with identified high risk

populations. Intervention programs that were particularly effective focused on changing

behavior rather than on changing attitudes and/or feelings (Elder, 1997).

Nursing Theory and the Nursing Meta-paradigm

King's Theory of Goal Attainment

Imogene King's (1981) theory of goal attainment is consistent with self- efficacy

and parent training. She defines persons as social beings who are rational, sentient,

perceiving, thinking, feeling, able to choose between alternative actions, able to set goals

[and] select means toward goals. Her meta-paradigm of the nursing process relies on a

conceptual framework of three systems: (a) the personal, relating to the individual, (b) the

interpersonal, involving the interaction between individuals particularly the nurse and

patient, and (c) social, involving the individual's relationships with family and other

external systems. It is in the context of this interpersonal system that nurse and patient set

goals and evaluate their achievement (Burney, 1991).

Parent training of young mothers, by nursing, in the context of King's theory is the

interpersonal system that the nurse and patient set goals and evaluate their achievement.

The key to King's theory is this nurse-patient transaction. The personal system is just as

vital to the theory, because it recognizes the significance of different perceptions of the

nurse and patient especially since transactions require perceptual accuracy in nurse-client









interactions and congruence between role performance for nurse and client (Chinn &

Kramer, 1991). King suggests that it is the capacity of human beings to interact

meaningfully with one another in the pursuit of common goals that allows progress of the

patient on all three levels (Aggleton & Chalmers, 2000). King's theory effectively

demonstrates that communication, goal setting and attainment are ways to help patients

meet their self care needs, one of the main goals of nursing. This can be translated to the

achievement of self- efficacy.

Congruence of King's Theory with Bandura's Self Efficacy Theory

According to Bandura (1997), individuals' self-efficacy beliefs powerfully

influence their attainments. He views people as self-organizing, proactive, self-reflecting

and self-regulating. From his theoretical perspective, human functioning is viewed as the

product of a dynamic interplay of personal, behavioral, and environmental influences.

This is the foundation of Bandura's (1986) conception of reciprocal determinism, the

view that (a) personal factors in the form of cognition, affect, and biological events,

(b) behavior, and (c) environmental influences create interactions that result in a triadic

reciprocity, a framework for self efficacy. It is evident that these two theories, Bandura's

self efficacy theory and King's theory of goal attainment, though from different fields

and perspectives, are congruent.

In Bandura's self- efficacy framework, nursing interventions can be viewed as

environmental influences that may effect change. In King's theory, nursing is part of the

interpersonal system. She acknowledges the importance of the nurse's role in assessing

the environment and making alterations conducive to promoting health.









Implications for Nursing Practice

In light of the current managed care era and the emphasis on health promotion and

disease prevention, nurses who work with families of young children are charged with

identifying and implementing effective early intervention strategies that promote positive

parent-child interactions (Elder, 1995; Tucker et al., 1997).

Consistent with King's nursing meta-paradigm and the preceding theoretical

linkages described, it is apparent that good assessment or obtaining a baseline of behavior

is an important step in the nursing process as well as being an imperative phase in

effecting change. Nurses must be able to identify individual family values and needs, set

goals in collaboration with the family and modify effective intervention strategies such as

parent training to match the identified needs and goals of individual mothers while

maintaining the essential components of the intervention for reaching the desired

outcome of self efficacy in the young mother.

Summary

A mother's attachment to her infant is recognized as a major contributor to the

child's healthy growth and development. Attachment theory postulates that certain inborn

behaviors such as crying, reaching and smiling in human neonates are exhibited in order

to bring a protective, nurturing attachment figure into close proximity (Bowlby, 1982).

This closeness provides the infant with security and gratification and serves as the

blueprint for all later attachment relationships. Disturbed attachments have been

implicated in the development of dysfunctional parent-child relationships and other

negative psychosocial outcomes.

Although a plethora of research has been done on this subject, very few studies

have been conducted in the recent past. Much of the research available for review was









conducted in the 1980's and 1990's. Review of this literature suggests that a

disproportionate percentage of insecure attachments have been found in infants of

adolescent mothers. Studies also reveal that a greater than expected incidence of

intellectual delays and/or behavioral disturbances is found in children of adolescent

mothers. Since adolescents are responsible for almost 500,000 births in the United States

annually (Ventura, Martin, Curtin & Matthews, 1998) and the emphasis on health care is

primary prevention, it is imperative that effective interventions are established to help

improve the long-term outcomes of these children.

Over the years, a number of infancy intervention programs have been developed to

overcome interaction disturbances with parent training. Although many of the

interventions described are dated, they demonstrate that through early intervention,

mothers learn the skills necessary to provide their infants with a nurturing environment

(Lambert, 1998). Badger (1980) reported significant gains for infants and increases for

the mothers in self-esteem after implementation of parent-training interventions of at risk

mother-infant pairs. Similarly, Field (1980) reported encouraging results in her work with

adolescent mothers and their preterm infants.

It has also been suggested in more recent literature (Kelly & Barnard, 2000) that

the experimenter-mother interaction provides emotional support for the mothers

participating in intervention programs and that such support is an important variable

enhancing the quality of maternal behavior. Further, several researchers have suggested

that professionals' intervention behaviors should serve as models for parent-child

interaction behaviors (Koniak-Griffin, Verzemneiks & Cahill, 1992; Kelly & Barnard,









2000.). However, there is little information on the best conditions of intervention and its

effect on later development.

Statement of Purpose

The purpose of this study is to examine the effects of a bug-in-the-ear feedback

parent training intervention on interaction behaviors between the adolescent mother and

her infant. There are three specific aims for this study. The first is to identify and

characterize the frequency of attachment behaviors exhibited in the infant/adolescent

mother dyad and obtain a baseline of the frequency of the interaction on the NCAST

Parent Child Interaction Scale. The second aim is to implement an individualized bug-in-

the-ear feedback parent training model to improve the frequency and quality of infant-

mother interaction and assess its efficacy using the NCAST Parent Child Interaction

Scale. The third aim is to compare operationalized mother/infant attachment behavior

frequencies pre and post training.

Research terminology used in this study will be presented in later chapters.














CHAPTER 2
REVIEW OF THE LITERATURE

Importance of Mother Infant Interaction

Guralnick & Neville (1997) summarize 20 years of prevention and early

intervention research and conclude that social competence is increasingly perceived as

the central focus in the psychological development of children. The central aspect of a

child's social competence and confidence is a secure attachment providing the growing

child with the resilience, trust and ability to regulate emotions. There is compelling

evidence that very early experiences are related to later development and antecedent

studies consistently reveal that specific patterns of interaction during the first year are

systematically related to attachment quality of the infant (Svanberg, 1998). Parental

antecedents of particular interest have been the mother's sensitivity, emotional warmth

and support as well as synchrony and mutuality in the interaction (De Wolff & van

Izendoom, 1997).

Importance of interventions in adolescent mothers

As Steele and Steele (1994) note, it is fortunate that a majority of mothers are

secure, affectionate and consistent. However, it has also been suggested in the literature

that adolescent mothers by virtue of their immaturity have difficulty establishing optimal

interactions with their infants and this may compromise infant growth and development

(Starn, 1992).

Although research conducted on adolescent mother infant interactions dates back to

the 1980's and 1990's, the long impact continues to resonate in public policy In 2000,









President Clinton called on Congress to enact his budget initiative to provide $25 million

to support living arrangements for teen mothers, help reduce repeat pregnancies and

improve the help of mothers and children (US Department of Health and Human

Services, 2000). The federal government estimates that approximately $40 billion per

year is spent on helping families that begin with a teenage birth. Studies indicate that

providing early intervention programs can reduce federal spending on adolescent

pregnancy sequelae (Nguyen, Parris, & Place, 2003). The Nurse Home Visitations

Program in Elmira, New York, based on the David Olds Home Visitation Model has been

found to be very effective (Karoly et al., 1998).

Review of Intervention Literature in the Adolescent /Mother Infant Dyad

Over the years, a number of other infancy intervention programs have been

developed in a variety of high risk populations to overcome interaction disturbances with

parent training. Because the innate characteristics of an infant are difficult or impossible

to alter, interventions practiced to date have focused on the behaviors of the mother or the

primary caregiver. The goals of these interventions have been to increase competence of

the parent in interpreting and responding to the infant's communication cues by

alleviating distress and promoting growth fostering behaviors, in essence to promote

synchrony (Barnett, Morisset & Spieker, 1993).

In a recent study, parent-child advocates were trained to provide one-on-one

intervention facilitating healthy parent-child interactions in a homeless population. They

focused on training parents how to increase sensitivity and responsiveness to their

children. Specific, positive and individualized feedback to parents related directly to

increasing the quality of the parent-child interaction (Kelly, Buehlman & Caldwell,

2000). Other researchers also have examined strategies used by effective parent trainers









to produce changes in parent behaviors (Dangel & Polster, 1984). Strategies identified as

successful include clear directions and specific feedback with praise.

Hester, Kaiser, Albert and Whiteman (1996) found that coaching, providing

positive examples, giving specific instructions and giving specific rather than general

feedback were effective parent training strategies and concluded that early intervention

personnel should be taught to use these strategies in the early intervention setting.

Bernstein et al (2001) emphasized that in order to support the parent-child relationship,

an interventionist must go beyond traditional early intervention and parent education.

Instead emphasis should be placed on the verbal and physical ongoing communication

between each mother and their vulnerable child.

In summary, it is evident from the preceding literature review that effective mother-

infant interaction may be compromised in the adolescent mother/infant dyad, leading to

negative outcomes in the child. It is therefore imperative that current, effective

interventions are established to help improve the long-term outcomes of these children. A

majority of the adolescent parenting programs described in the literature are group

oriented and are not directed at improving the mother-infant interaction. Instead they

focus on the acquisition of knowledge and skills to increase competence in caring for the

infant.

Further it is important to recognize that different adolescent mothers will have

varied strengths and may need different kinds of help with regard to preventative

strategies (Svanberg, 1998). A one-size fits all approach to intervention may not always

apply to the individual mother/ infant dyad. These shortcomings clearly underscore the

importance of using an alternative research approach in exploring effective parent









training interventions. More research is needed on low cost training strategies that are

uniquely suited for individual caregiver needs. Therefore, the proposed study will address

these concerns by employing a single subject design and an individualized intervention

with antecedent stimulus delivered to the adolescent mother via a simple wireless

earphone, also referred to as bug-in-the-ear (BITE) feedback.

Bug-in-the-ear feedback (BITE)

Immediate feedback has been found to be more effective than delayed feedback in

increasing desirable behaviors such as teaching, how to deliver positive consequences

and instructional prompts (O'Reilly, Renzaglia & Lee, 1994). For example, Lancioni &

Boelens (1996) demonstrated the efficacy of immediate computer delivered feedback in

increasing the drawing accuracy of children with mental retardation.

A number of studies have used the bug-in-the-ear feedback to deliver immediate

feedback. Such studies fall into three categories. One area of focus is providing

immediate and corrective feedback to counseling trainees with the overall aim of

improving clinical intervention skills (Gallant, Thyer & Bailey, 1991). A second area of

focus using BITE is with teachers with emphasis on skill acquisition and finally using

BITE with parents who are provided immediate feedback when dealing directly with their

children, the focus on increasing desirable parenting skills (Crimmins, Bradlyn, St.

Lawrence & Kelly, 1994; Wolfe et al., 1982).

Advantages of using an earphone that receives a transmitted signal are numerous.

In addition to minimizing disruption and providing immediate feedback, the use of

electronic instrumentation such as the BITE device can be used when individuals are not

trained in complex intervention techniques (Coleman, 1970). It also eliminates the risk of

observer influence when used for intervention training. Further, with today's









technological advances, this technique may fit well with the learning styles of today's

adolescent. Accustomed to immediate gratification, youth today are responsive. They

crave stimulation and expect immediate answers and feedback (Brown, 1997). Bug-in-

the-ear technique may be a good tool for intervention for this generation.

Single Subject Design

Single subject design, derived from behavior analysis, is a research design that

provides an experimental model for the study of individuals over time. The design is a

clinically viable, controlled experimental approach to the study of a single case or several

subjects, and the flexibility to observe change under ongoing treatment (Portney &

Watkins, 2000). Single subject design requires the same attention to logical design and

control as any other experimental design based on a research hypothesis. The

independent variable is the intervention and the dependent variable is the subject's

response defined as the target behavior that is observable, quantifiable and a valid

indicator of treatment effectiveness (Portney & Watkins, 2000).

Single subject design is widely used in behavior analysis research where it

originated from and also in treatment design and intervention testing research in an array

of fields including special education, social work and learning disabilities as well as in a

number of allied health researches ranging from occupational therapy, physical therapy,

disability rehabilitation and medical gastroenterology (Elder, 1997; Madsen & Bytzer,

2002; Zhan & Ottenbacher, 2001;). The gold standard of nursing research thus far

remains the group comparison design with a dearth of nursing research studies using

single subject design.

There are numerous characteristics of single subject design that makes it a powerful

research approach, particularly when dealing with individual subjects. Those elements






23


that distinguish single subject design from group designs or case study include baseline

logic; each subject serving as his own control; replication and visual analysis of the data

(Bailey & Burch, 2002). This methodology is most appropriate for this research question

that addresses the individual's behavior as well as the subject serving as her own control.

Furthermore, by replicating the single subject intervention with several single subjects it

may be possible to obtain a generalized overall intervention effect.














CHAPTER 3
METHODOLOGY

Participants and Setting

Three adolescent mothers and their infants participated and completed this study.

Inclusion criteria for the participants were based on conditions that are optimal for

mother/infant interactions and also based on conditions that minimized the risk of the

impact of confounding variables such as age, racial and cultural differences on interaction

behaviors. Thus, mothers recruited : (1) were close in age (2) were between the ages of

13 and 18years (3) were of similar race and socio-economic background (4) had no

previous parenting experience (5) had a vaginal delivery and (6)were in good mental and

physical health as determined by their health care provider. Inclusion criteria for the

infants were(l) thirty six weeks gestation or greater (2) no congenital abnormalities (3)

between the ages of zero and six months (4) formula fed and (5) in good general health

as determined by their health care provider.

Excluded from this study were mothers who were (1) older than age 18 years (2)

had previous parenting experience (3) had experienced a cesarean section (4) in poor

mental and physical health as determined by their health care provider. Exclusion criteria

for the infants were (1) less than thirty six weeks gestation (2) presence of congenital

abnormalities (3) greater than six months of age. (4) currently breast feeding and (5)

infants in poor health as determined by their healthcare provider. Formula feeding was

used as an inclusion criteria to minimize the possible psychological discomfort associated

with videotaping in this population, particularly when breast feeding. Further,









mother/infant interactions are likely to be different when formula feeding versus breast-

feeding.

Capital City and Gadsden County Healthy Start Programs are community action

programs that provide free comprehensive early childhood health and education programs

to low income children while involving their parents in the total child development

process. Pregnant adolescents are an integral part of this program. After obtaining

approval from the University of Florida Institutional Review Board (IRB) and Florida

Department of Health IRB, three adolescent mothers and their children and three

alternates were recruited from this setting through a Healthy Start Social Worker.

In an effort to reduce participant attrition, the Investigator frequently checked in by

phone and maintained contact with the mothers of the participants as well as the Social

Workers of the Gadsden County and Capital Area Healthy Start.

Pilot Testing

All procedures including instruments and the intervention were pilot tested with an

18-year old participant and her 6-month old infant who were not part of the study. The

data from the pilot study provided important insight regarding how the study was to be

conducted particularly in terms of the mechanics of videotaping and the delivery of the

intervention.

Participant 1

Participant 1 was a pleasant, cooperative 15 year-old, single African American

young woman who lived at home in the Tallahassee area with her mother and four

teenaged siblings. She was entering the 10th grade in an alternative school in the fall

semester. This was her first pregnancy. Her pregnancy was uncomplicated and baby was

vaginally delivered at term.









Infant 1

This was a 3-month old African American male infant delivered vaginally at term.

He weighed 6 pounds and 11 ounces at birth He was healthy with no congenital

abnormalities. He was on Carnation Good Start formula for the first three sessions and

was changed to Isomil formula due to frequent episodes of diarrhea. His weight was

appropriate for his age and he had a healthy appetite.

Participant 2

Participant 2 was also a 15 year-old, single African American young woman who

lived at home in the Tallahassee area with her mother and two teenaged siblings. She was

also entering the 10th grade in a local high school in the fall semester. This was her first

pregnancy. She also had an uncomplicated pregnancy and baby was vaginally delivered

at term.

Infant 2

This was a 51/2-month old African American male infant delivered at term,

weighing in at 6 pounds and 7 ounces. He was healthy with no congenital abnormalities.

At age 51/2 months, he was rather large for his age. He ranked in the 85th percentile for

height and over the 99th percentile for weight. He was on Isomil formula and recently had

begun taking solid foods.

Participant 3

Participant 3 was a 15 year-old African American young woman who lived at home

with her mother and two teenaged siblings in the Quincy/Havana area. This was her first

pregnancy. Her pregnancy was uncomplicated except for one admission for pre-tem labor

in the 7th month. Her baby was delivered vaginally at term. She was entering the 10th

grade of an alternative high school in the fall semester.









Infant 3

This was an 11/2- month old African American male infant delivered at term. He

weighed 7 pounds and 2 ounces at birth. He was healthy with no congenital

abnormalities. His size was appropriate for his age. He was on Carnation Good Start

formula and had a healthy appetite.

Procedures

At each mother's home, the study was thoroughly explained and informed consent

obtained from the participants' mothers (since each participant was an adolescent and

there was no parental involvement of the fathers of the babies of all three participants).

Assent was obtained from each of the adolescent mothers. During the first visit, each

participant was asked about general information and appointments were then made for

subsequent home visits when videotaping occurred.

Experimental Procedure

A non-concurrent multiple baseline design across participants was used. The

demonstration of experimental control in the multiple baseline design depends upon

approximately equal effects of the treatment being observed with each baseline. The

experimenter needs to ensure that the baselines are as functionally equivalent as possible

(Bailey & Burch, 2002). Therefore, baseline videotaping was done at the 1.00 pm feeding

of the infants of all three 15 year-old mothers. After baseline stability was reached, the

intervention phase was instituted but staggered, several days to several weeks apart,

across participants due to their different schedules and availability. A modified

intervention (Intervention 2) was instituted for the first two participants after only subtle

changes in target behaviors were observed after the first intervention was instituted. The

third participant received the modified intervention only.









There were a total of nine sessions for Participant 1, eight sessions for Participant 2

and six for Participant 3 (see Table 3-1). At the conclusion of the study all adolescent

mothers received a gift certificate of $25-$35 (depending on the number of sessions).

Table 3-1. Videotaping Schedule of Participants
Baseline Sessions Intervention 1 Intervention 2

Participant X X X X X X X X

1

Participant X X X X X X X

2

Participant X X X X X

3


Baseline Phase

The Investigator videotaped each mother-infant dyad at home during numerous

(three to four) 1:00 pm feeding sessions. Baseline videotaping during feeding was done at

the same time of each day for all participants. To minimize the risk of observer influence,

the camcorder was set up on a tripod following pre- established guidelines (obtained after

a pilot study) and the Investigator waited in a different room while each mother fed the

baby.

The baseline sessions were repeated until a stable baseline of interaction behaviors

was achieved. The individualized intervention was designed and instituted based on the

occurrence or non occurrence of target behaviors that were identified during the baseline

phase.









Intervention

To minimize observer influence and/or bias, an instant replay camcorder set on a

tripod was used during the intervention phase. This device transmitted instant images to

the Investigator on a portable television set and allowed the Investigator to prompt, cue

and provide reinforcement to the participants via a wireless headphone on desired

behaviors from a different room. The first intervention involved the Investigator's

randomly interjecting several prompts for desired behaviors and providing reinforcement

when the desired behaviors were exhibited. After several sessions with this intervention

with the first two participants, very subtle changes in target behavior were noticed. After

debriefing with the participants, a very structured modified intervention was developed

where prompts, cues and reinforcements were given in sequence. In addition, the

language used in delivering the prompts was simplified and specific examples of the

target behavior were also given. The instant replay was also eliminated at this time. This

modified intervention incorporating participant feedback was instituted with all three

participants and found to produce a significant change in target behaviors. As a result of

the first two participants' positive response to the modified intervention, Participant 3

received this modified intervention only after her baseline stability was achieved.

Instruments for Evaluating Dependent Variables

NCAST

The Nursing Child Assessment (NCAST) Feeding scale was used to operationalize

attachment behaviors as well as code attachment behaviors as they occurred in

videotaped mother-infant interactions. This scale has been widely used in assessment of

attachment behaviors and has been subjected to much validity and reliability testing. The

content validity for NCAST was derived from the Bayley Test of Infant Development,









the Merrill Palmer and Stanford -Binet Scales and later modified according to the

observations of William Frankenberg (NCAST, 1995).

The scale demonstrates high internal consistency of the total score, parent score and

the infant score. The Crohnbach's alpha for the total parent score is .87 and for the total

child it is .81 (NCAST, 1995). The test-retest reliability is better for the parent items than

for the infant items. The total score generalizibality coefficient for the parent score is 0.75

and lower for the infant, 0.53 (NCAST, 2000). The validity of the scale predicting later

IQ has been established in several samples. A longitudinal intervention project follow up

revealed that scores for fostering of cognitive growth from the 10 month feeding scale

showed a correlation of).50 with the child's Bayley Mental Developmental Index at 24

months of age (NCAST, 2000).

The scale is based on the Barnard Model that assumes that mothers and infants

have certain "responsibilities" to keep the feeding interaction going. The infant has the

role of producing clear cues and being responsive to the mother. The mother has the

responsibility of responding to the infant's cues, alleviating the infant's distress and

providing opportunities for growth and learning (NCAST, 2000). The NCAST Feeding

Scale is therefore divided into five categories under which there are a number of

subcategories of attachment behaviors.

In this study, due to the exhaustive nature of the items on the original NCAST

Feeding Scale, it would have been very difficult to code the videotaped sessions of all 76

behaviors in the subcategories. Therefore four out of the five major categories were

assessed. These important attachment behaviors were identified and operationalized using

previous research in this area as well as the opinions of expert panel of pediatric health









care professionals. A family care physician with a pediatric focus and three registered

nurses were surveyed informally on the most important behaviors in the selected

attachment categories. The categories were: mother's sensitivity to cues, mother's

providing growth-fostering situations, infant's clarity of cues and infant's responsiveness

to mother. The category of alleviation of distress was eliminated because there was not a

consistent opportunity for those target behaviors to be exhibited during the baseline phase

of the study. Further, only 13 selected behaviors in the subcategories were measured.

According to the literature, the NCAST scale has been modified and adapted for a

number of reasons, including the culturally modified scale (Leon Siantz, in press).

However, the rate of occurrence of attachment behaviors and the resulting implications

have not been explored in the NCAST literature. In fact, the NCAST scale only measures

the presence or absence of attachment behaviors. A number of studies have documented

the internal reliability of the categories or subscales of the NCAST tool (Mogan, 1987;

NcNamara, 1985). NCAST related research reports that the categories or subscales of

sensitivity to cues, clarity of cues and responsiveness to parents as being the poorest in

internal consistency reliability, yet there is no documentation in the literature on studies

that have explored the reliability of the individual subscale items (NCAST, 2000). This

lack of documentation on the reliability of the subscale items of this tool is a flaw of

NCAST as a research tool. In this study, occurrence rate of individual, specific, subscale

attachment behaviors was examined.

Operational Definitions

Independent Variables

Sensitivity to cues. The three target behaviors for this category of attachment

behaviors were:









* Mother positions the infant so that the infant's head is higher than her hips.

* Mother comments verbally on infant's hunger cues before feeding.

* Mother positions the child so that trunk to trunk contact is maintained during
feeding.

Social-emotional growth fostering. The three target behaviors for this category of

attachment behaviors were:

* Mother is in "en face" position for more than half of the feeding.
* Mother uses positive statements in talking to the child during the feeding
* Mother smiles during the feeding.

Cognitive-growth fostering. The three target behaviors for this category of

attachment behaviors were:

* Mother talks to the child using two words at least three times during the feeding.
* Mother verbally describes the feeding or feeding situation to the child.
* Mother talks to the child about things other than the feeding.

Clarity of cues. The three target behaviors for this category of attachment

behaviors were:

* Child displays a "build up of tension" at the beginning of each feeding. This was
further operationalized as the child shaking his head from side to side, crying and
looking for the bottle at the beginning of each feeding.

* Child demonstrates a decrease in tension within a few minutes after feeding has
begun. This was further operationalized as the child stops shaking his head from
side to side and stops looking for bottle.

* Child's readiness for feeding. This was further defined as child's eagerness to feed
and looking in the direction of the bottle. This target behavior was not included in
the final analysis of the study because of the difficulty in distinguishing it from the
target behavior of builds up tension.

Responsiveness to Mother. The two target behaviors for this category of

attachment behaviors were:


* Child looks in the direction of the mother when feeding.









* Child responds to feeding. This was further operationalized as child relaxed with
rhythmic breathing as he sucks on the bottle.

Dependent Variables- Frequencies of Mother and Infant Attachment

Behaviors. Different aspects of this tool have been used in similar studies where

videotaped sessions were scored and coded for presence of behaviors, thus the NCAST

staff were qualified in training the coders. The NCAST trainers are selected advanced

practice nurses trained at the University of Washington where the NCAST tool was

developed.

In order to establish inter -observer reliability, two nurse observers, were trained to

use the NCAST tool. A third observer, who was not a nurse and who had not been trained

in the use of the scale by the NCAST staff, was trained by a trained observer using the

NCAST materials. The three independent observers coded target behaviors of the

videotaped sessions. The time interval coding method was used for the target behavior.

Infant feeding for participants lasted between 6 1/2 minutes and 11 minutes. Thus, 6

minute sessions of each videotaped interaction were coded and frequencies of

occurrences of behaviors were recorded every 20 seconds.

Inter-observer Reliability

Inter-observer reliability checks were randomly obtained for 50% of all behaviors

coded and frequencies measured. The reliability checks were conducted by the three

observers independently viewing the videotapes at least twice at one sitting, three days

after the initial coding was completed. Inter-observer agreement was calculated on an

interval by interval basis for coding of mother and infant behaviors by calculating the

number of agreements divided by the number of agreements plus the number of

disagreements (Bailey & Burch, 2002). In this study, intervals in which target behaviors









were not observed were counted as agreements for the behaviors that occurred in high

frequency and were not counted for behaviors that occurred in low frequency. The inter-

observer agreement on the behavior coded was averaged to obtain the overall inter-

observer agreement for each attachment behavior coded. Inter-observer reliability of 83%

to 100% was obtained for the various behaviors coded using this interval agreement

calculation (see Table 3-2). The subscale item of the infant's readiness to feed was

eliminated from the study because of consistently poor reliability scores and the difficulty

the observers had in distinguishing that behavior from the behavior of build up in tension.

Data Analysis

As is customary with single subject experimentation, the data were analyzed

visually for the trends or direction of change in behaviors, which may refer to the value

or magnitude of the performance at the point of the intervention compared to the

baseline. Since a multiple baseline design was employed in this study, data points at

baseline and intervention were closely examined for trends, stability and variability as

well as replication of the previous condition. The slope of the trend for baseline,

intervention and modified intervention phases was assessed for a linear trend.

Table 3-2. Inter-observer Reliability
Behavior coded Participant 1 Participant 2 Participant 3 Mean


Head higher than hips


100%


Reliability

100% 100% 100%


Trunk to trunk position


100% 100%


100% 100%









Comments on child's


hunger


Enface position


100%


Smiles during feeding



Uses positive statements



Talked to child using 2 +


75%



87.5%



100%


100%


87.5%



87.5%



100%


words


Describes feeding

situation

Talks to child about other


100%



87.5%


100%



75%


75% 92%


87.5% 83%



87.5% 87.5%


100%


%

100% 100%



87.5% 83%


things


Response to feeding

Looks in Mother's

direction

Builds up tension

Decrease in tension

****Readiness to feed


**** This attachment behavior was not included in the final analysis of the study


100%

87.5%



100%

100%

48%


100%

75%



100%

100%

48%


100%

87.5%



100%

83%

48%


100%

83%



100%

96%

48%


100%


100%


100% 100%














CHAPTER 4
RESULTS

Findings

Coding of six minute feeding sessions revealed that in the baseline phase of the

study, all three participants exhibited higher frequencies of attachment behaviors that

were task oriented and exhibited low frequencies of attachment behaviors that involved

communication with the infant. Attachment behaviors that were exhibited in low

frequency were the target of the individualized intervention. Multiple baseline design

demonstrated the replication of intervention effects across participants. Experimental

control was strengthened by the display of independent baselines and the observation of

change in the target behavior only when the intervention was instituted. The data for

baseline and intervention phases were graphed. Pictorial representation of interventions

for the low frequency target behaviors demonstrated that there was a cause and effect

particularly between the modified intervention and the target behaviors.

Sensitivity to Cues

In the baseline phase all three adolescent mothers consistently exhibited the

behaviors of positioning the infant's head higher than hips and maintaining the trunk to

trunk position the majority of the feeding time. The frequency of maintaining the position

of the infant's head higher than hips was almost at the ceiling across all participants

except during the third baseline session with Participant 1, when she had a lower than

usual frequency of this particular target behavior as well as the behavior of maintaining

the trunk to trunk position. She however went back to her baseline for both behaviors in









the subsequent session. Participant 2 also had a consistent lower frequency compared to

the other participants of maintaining trunk to trunk position in all sessions. However, she

had a larger baby which may explain the lower frequency of this particular target

behavior in this participant (see Table 4-1 and 4- 2).

Table 4-1 Sensitivity to Cues: Frequency of Infant's Head Higher than Mother's Hips
Baseline Baseline Baseline Baseline

Session 1 Session 2 Session 3 Session 4

Participant 1 18 17 13 17

Participant 2 18 18 18

Participant 3 18 18 18





Table 4-2 Sensitivity to Cues: Frequency of Mother Maintaining Trunk to Trunk Position
Baseline Baseline Baseline Baseline

Session 1 Session 2 Session 3 Session 4

Participant 1 14 14 12 14

Participant 2 9 10 10

Participant 3 16 14 16


Conversely, all three adolescent mothers rarely commented on the infant's hunger

during the baseline sessions, thus this behavior was the target for intervention in this

category across participants (see Figure 4-1).

Participant 1

During the four baseline sessions, this participant never commented on her infant's

hunger cues. The first intervention resulted in a subtle change in behavior from a









frequency of 0 during feedings to a maximum frequency of 3 in the intervention phase.

The modified intervention resulted in the highest increase in frequency up to 5 comments

made during a feeding (see Figure 4-1).

Participant 2

Similarly, Participant 2 rarely commented on her infant's cues. She made a

maximum of 2 comments related to her infant's hunger cues during the baseline phase.

The first intervention yielded a maximum of 3 comments. The modified intervention

resulted in this participant making 6 comments during a feeding related to the child's

hunger (see Figure 4-1).

Participant 3

Participant 3 commented only once on her infant's hunger cues during two of the

feeding sessions of the baseline phase. She received the modified intervention only,

which resulted in minimum of 4 and a maximum of 5 comments being made related to

the infant's hunger at each feeding session in the intervention phase (see Figure 4-1).

Social-Emotional Growth Fostering

Coding selected behaviors for the attachment category of social-emotional growth

fostering revealed that across participants all three adolescent mothers displayed high

frequencies of maintaining enface position with the infant (see Table 4-3). In contrast,

there was a low incidence of the selected behaviors of smiling during feeding and using

positive statements towards the infant during feeding across all three participants.














Table 4-3 Social- Emotional Growth Fostering. Frequency of Mother Maintaining Enface
Position
Baseline Baseline Baseline Baseline

Session 1 Session 2 Session 3 Session 4

Participant 1 16 18 10 18

Participant 2 16 16 15

Participant 3 18 18 15


Accordingly, the two identified behaviors of smiling during feedings and using

positive statements towards the infant were the targets for intervention. Again in the

fashion of multiple baseline design experimental control was determined by the

independent baselines (see Figure 4-2).

Participant 1

During the four sessions in the baseline phase, this participant smiled only once and

never made any positive statements during feeding sessions. There was a significant

improvement in the frequency of the target behavior of smiling during feeding after the

first intervention up to 3 smiles during a feeding and an even higher frequency of smiling

after the modified intervention up to a maximum of 7 times. On the other hand, there

was a very subtle to no change in the behavior of using positive statements with the child

after the first intervention. Both participants in the first intervention admitted to having

difficulty formulating positive statements. Thus, with the modified intervention, specific

examples such as "he is so cute" and "he is beautiful" were given as prompts. This









resulted in a slight increase in the frequency of the target behavior of using positive

statements in this participant (see Figure 4-2).

Participant 2

Participant 2 had a much higher frequency of smiling during the baseline phase.

She smiled up to 4 times during a feeding session. However, she rarely used positive

statements in the baseline phase. The first intervention resulted in an increase in smiling

behaviors. The modified intervention resulted in an even greater increase. Consistent with

the first participant's pattern, the first intervention did not lead to any significant changes

in the use of positive statements in this participant. The modified intervention however

resulted in an increase, up to 5 comments made per feeding session in this phase (see

Figure 4-2).

Participant 3

This mother rarely smiled or used positive statements during the three baseline

sessions. During the modified intervention phase, she smiled up to 7 times per feeding

and made up to 6 positive statements about the infant per feeding session (see Figure 4-

2).















Structured prompts


Participant 3


1 2 3 4 5 6


Structured
Prompts


Baseline















1 2 3


Baseline


Prompts


Participant 2


4 5 6 7







Prompts


1 2 3 4 5

S"p;irm<


6 7 8 9


4


E 3







0
' 2

S1

g- 1


8




Structured
Prompts













Participant 1


Figure 4-1.Frequency of mother's comments on infant's hunger during baseline and
intervention phases


Baseline













Prompts
Baseline


Participant 3



3 4 5 6


Prompts


1 2 3 4 5 6 7



Sti


Baseline


Participant 2



8



ructured prompts


Prompts


Participant 1


1 2 3 4 5 6 7 8 9


Figure 4-2 Frequency of mother's smiles and use of positive
and intervention phases


statements during baseline


1 2


Baseline


Structured
prompts


*.









Cognitive Growth Fostering

All three selected behaviors of the attachment category of cognitive growth

fostering were communication behaviors. The frequencies of the behaviors of talking to

the infant using more than two words; the number of times the mother described the food

or the feeding situation as well as the frequency of talking to the child about other things

were coded in each feeding session. Intervention was targeted for all the three selected

behaviors in this attachment category. The baseline behaviors and intervention effects are

illustrated in Figure 4-3.

Participant 1

This participant talked to her infant using multiple words once during the first

baseline session and three times during the third baseline session. She did not exhibit this

behavior during the other two sessions in the baseline phase. Further, she never

described the food nor did she talk to the infant about other things during all four baseline

sessions. There was a significant improvement in the frequency of the mother using more

than two words and talking to the child about other things in the first intervention and yet

a further increase in the frequencies of these two behaviors with the modified

intervention. There was only an overall slight improvement in the frequency of

describing the food and the feeding situation (see Figure 4-3). This participant reported

that this selected behavior was irrelevant. In her words "how can you describe formula?"

Participant 2

This participant used multiple words two times during the first baseline feeding

session and did not repeat this particular behavior during the remainder of the baseline

phase. She also, never described the food nor to talk to the child about other things during

the baseline phase. Similar to the previous participant there was a significant









improvement in the frequency of this participant using more than two words and talking

to the infant about other things in the first intervention and yet a further increase in the

frequencies of these two behaviors with the modified intervention. Additionally, there

was only an overall slight improvement in the frequency of describing the food and the

feeding situation.

Participant 3

The only cognitive fostering behavior exhibited by this participant in the baseline

phase was using multiple words once in the first baseline session. After receiving the

modified intervention, there was an increased frequency of all three behaviors, although

the behavior of describing the food increased in frequency minimally (see Figure 4-3).

Child's Clarity of Cues

All three infants consistently exhibited clear hunger cues. There was an inverse

relationship between the frequency of building up tension behaviors and the frequency of

decreasing tension behaviors (see Table 4-4 and Table 4-5). This suggests that the infants

appropriately exhibited hunger cues and were appropriate in their response to the feeding.

Table 4-4 Child's Clarity of Cues-Builds up Tension
Baseline Sessions Intervention 1 Intervention 2

Infant X X X X X X X X


X X X


X X X X X


X X X


Infant


Infant


X X X












Table 4-5 Child's Clarity of Cues-Decrease in Tension
Baseline Sessions Intervention 1


Intervention 2


14 9


Infant

1






Infant

2






Infant













Structured prompts








Participant 3


1 2


Baseline


3 4 5 6


Promp


1 2 3


Baseline


)ts


Structured prompts


* 4-Uses 2+ words









Participant 2


4 5 6 7 8





..... ................... Structured prom pts

Prompts


8
o
> 7


5
C-
S4

02
* 3


>1
C 2

D
LL












(D

-0
0

.)
ci

C






L,
o
M-

><
C,

0-


Talks to child
about other
things


Describes
,. food


Participant 3


1 2 3 4 5 6 7 8 9


Sessions


Figure 4-3 Frequency of mothers exhibiting cognitive growth behaviors during baseline
and intervention phases


Baseline


7
.0o
-
.1l
5
I 4
0
2 3
o2

L)
g 1
un


.7.-.


10

9

8

7

6

5

4

3

2

1

0


*A


X:










Child's Response to Mother

Although all three infants intermittently looked in the direction of their mother in

all feeding sessions in the baseline phase there was an increase in the frequency of this

particular target behavior with the communication interventions that were directed at the

adolescent mothers for the other attachment categories.

Infant 1

This infant looked in his mother's direction between 6 and 10 times per feeding in

the baseline phase. This behavior increased to a frequency of a maximum of 15 in the

first intervention phase and a further increase up to 16 in the modified intervention phase

(see Figure 4-4).


18 Mother receiving Mother receiving structured prompts
prompts
16 o-
Baseline
14
12
10

8 6

4 4







Figure 4-4 Infant 1 Frequency of infant looking in mother's direction

There was clearly a correlation between the intervention effects of the mother's

behavior and this particular target behavior of the infant. This was the second most

pronounced increase in frequency of all the target behaviors measured in this particular

mother/infant dyad (see Figure 4-5).
mother/infant dyad (see Figure 4-5).














Mother's
Baseline


8 Mother's
7 Baseline
6
5
4
3
2

1 r\


Prompts


f-,


Participant 1


Smiles and uses positive statements


1 2 3 4 5 6 7


10 Mother's
9 Baseline
8
7 -
6
5)
4




0
2

0 .


Prompts


8 9


Structured prompts


V-1


0. Uses cognitive growth fostering behaviors
Participant 1 (language)


1 2 3 4 5 6 7 8 9


Infant's
1 Baseline
o 14
12
10-




0_


Infant 1 Looks in mother's direction


Figure 4-5 Relationship between Infant 1 looking in mother's direction and target
behaviors during baseline and intervention phases


jX7E









Infant 2

This infant also looked in his mother's direction 6 to 9 times during a feeding

session in the baseline phase. This behavior increased to a maximum frequency of 15 in

the first intervention phase and up to 16 in the modified intervention phase (see Figure 4-

6 and Figure 4-7). This was the most pronounced change in target behaviors of this

particular mother/infant dyad.


18 Mother receiving
Baseline prompts Mother receiving
16 structured prompts


10 -
S12
10

8
o 6
SInfant 2




0
o 4
I 2
0 ------------------------------
1 2 3 4 5 6 7 8
S'p1VinnV

Figure 4-6 Infant 2 Frequency of infant looking in mother's direction

Infant 3

The behavior change in this particular infant was more conservative. He looked in

the direction of his mother 8 to 9 times per feeding session in the baseline phase. This

increased to a frequency of 12 and a maximum of 14 in the modified intervention phase

(see Figure 4-8). Although an improvement, the change in behavior was not as dramatic

in comparison to the other two mother/infant dyads (see Figure 4-9).















Structured prompts
Prompts










Participant 2 Comments on infant's hunger


Mother's Prompts
Baseline







4 5 6
1 2 3 4 5 6


Mother's
Baseline


Structured prompts

: U .------


Smiles and uses positive statements


Participant 2


7 8


Prompts Structured prompts

'--------


S 4 5
1 2 3 4 5 6


A-'


U.


Participant 2


Uses cognitive growth
fostering behavior (language)


7 8


18
161
14 Infant's
12 Baseline
10


4
2

1 2 3 4 5 6 7 8


Infant 2


Looks in mother's
direction


Figure 4-7. Relationship between Infant 2 looking in mother's direction and target

behaviors during baseline and intervention phases


Mother's
Baseline










16 Mother receiving
1 Baseline structured prompts
14

12

# 10
10

2 8
0
S 6
4 Infant 3
a 4

2

0
1 2 3 4 5 6

Sessions


Figure 4-8 Infant 3 Frequency of infant looking in mother's direction

Summary of Findings

Pictorial representation of interventions for the low frequency communication

target behaviors demonstrated that there was a cause and effect particularly between the

modified intervention and the target behaviors. The modified intervention consisted of

structured prompting followed by reinforcement for each target behavior exhibited. The

change in behavior was immediate in nearly every case and the resulting change in infant

behavior could be seen as well. The findings of the study also demonstrate the

importance of communication in mother/infant interactions.


























Participant 3


Comments on
infant's hunger
crUes


1 2 3 4 5 6


Mother's
Baseline


Participant 3


Smiles and uses positive
statements


1 2


7
o
3 6 Moth
Basel
5

4

S3
2
1


3 4 5 6



Structured
prompts


. .


her's
line


Participant 3


Uses cognitive
growth fostering
behaviors


1 2 3 4 5 6


Looks in Mother's direction


1 2 3 4 5 6


Figure 4-9. Relationship between Infant 3 looking in mother's direction and target

behaviors during baseline and intervention phases


m














CHAPTER 5
DISCUSSION

Overview

This study evaluated the effectiveness of a bug-in-the-ear feedback as an

intervention to promote attachment behaviors in the adolescent mother/infant dyad. The

intervention was based on an assessment of the frequency of occurrence and non-

occurrence of attachment behaviors coded and defined by the NCAST Feeding Scale.

The baseline phase of the study clearly identified low frequency and non-occurrence of

attachment behaviors of the verbal/communication type that required intervention.

Additionally, after the intervention was instituted in the second phase of the study there

were positive effects in the mother's behaviors which in turn positively impacted infant

behavior. This was particularly notable in the area of responding to the mother.

Findings from this study extend and strengthen previous research in this area that

has shown that adolescent mothers are less verbal to their infants (Brooks- Gunn &

Chase-Landale, 1995; Culp, Osofsky & O'Brien, 1996). Additional studies have

established the importance of interactions between a mother and her infant as crucial for

optimal child development (Beckwith & Cohen, 1984; Olson, Bates & Kaskie, 1992;

Sroufe, 1985). Infants exposed to greater verbal stimulation have been found to be more

likely to have better verbal comprehension later on in life (Lacroix, Pomerleau & Malcuit

2002; Olson, Bates & Bayles, 1984). However, a number of studies have documented

that African American adolescents communicate less with their infants (Barnett, Duggan,

Devoe & Bumell, 2002; Nitz, Ketterlinus & Brandt, 1995). Yet there is a dearth of









nursing research that explores the impact of this behavior on child development in

African American children. Additionally, there is a scarcity of recent intervention studies

focusing on African American adolescent/infant interactions in the nursing literature.

The findings of this study support the importance of interventions such as parent

training to improve the quality and frequency of attachment behaviors, particularly as

they relate to verbal behaviors of the adolescent mother and her infant. Improvement in

these mother/infant behaviors ultimately can have a positive impact on the child's

development.

This chapter will include discussion of important similarities and differences across

adolescent mothers in this study and across study phases. In addition, there will be a

discussion of the parent training, issues of recruiting and retention, limitations of the

study, recommendations for future research and implications for nursing practice, all with

linkages to theory.

Participant Characteristics and Behaviors

All three adolescent mothers were very similar in their social characteristics. They

were all African American, 15 years old, in the 10th grade, had a varying number of

teenage siblings, and lived at home with very supportive mothers who were heads of the

household, who had themselves been teenage parents. None of the infants' fathers were

actively involved in parenting. Behaviors observed across participants during feeding

sessions in the baseline phase were very similar. Although these young women were

pleasant, cooperative and quite talkative with the Investigator, they all remained very

quiet when feeding their infant and appeared to approach feeding as a task that had to be

completed. The adolescent mothers were very successful in exhibiting target attachment









behaviors in high frequency that were physical or task oriented including positioning the

infant appropriately, maintaining trunk to trunk and enface positions.

Further, all participants exhibited idiosyncratic behaviors during the baseline phase

which did not include any of the target attachment behaviors. These were also physical

and task oriented. Although not reported in the results section of the study, these

idiosyncratic behaviors were addressed with successful results during the intervention

phase. Participant 1 in all sessions interrupted the feedings between two to four times to

check the infant's bottle to see how much had been consumed and how much was left.

During baseline, Participant 2 prodded her infant to finish his feedings even when he was

obviously satiated. Participant 3 was very interested in keeping the infant's face clean. In

her first baseline session, she interrupted the feeding to remove a tiny piece of lint from

the infant's ear. During her third session, she interrupted the feeding to clean his nose.

Such physical behavior with relatively little verbal interaction has been shown in

previous studies (Osofsky & Osofsky, 1970; Sandler & Vietze, 1980).

Communication behaviors including smiling to the infant were minimal or absent

across all three participants. From a behaviorist standpoint, Skinner (1957) explained

verbal activity as an effect of environmental contingencies, particularly audience

response. Thus it can be postulated that adolescent mothers do not communicate with

their infants because they do not get a response. Actually one of the participants in the

study indicated that it was difficult to talk to an infant who did not talk back to her.

Participant 2 exhibited the highest frequency of communication behaviors in the baseline

phase. She smiled more and communicated more (compared to the other participants)

with her 51/2-month old infant who was the oldest infant in this group. This is probably









due to the fact that this particular mother responded to the infant's being more interactive

with her because of his stage of development. This behavior is consistent with research

reported in the NCAST literature suggesting that behaviors including maternal

vocalizations and mutual gaze increase with the age of the infant. McNamara (1985)

It was evident in this study that each infant responded to his mother's increased

verbal activity by gazing in the mother's direction. There was an increase in frequency of

infants looking in their mother's direction during the intervention phases. These infants

were obviously stimulated by their mother's voice and had their attention captured. Infant

3 had the lowest improvement in the frequency of this target behavior of looking in the

mother's direction. He was also the youngest infant (11/2 months old) in this group.

Again, this finding was consistent with McNamara's (1985) research.

In order to improve mother/ infant communication earlier on in the infant's life,

interventions such as those used in this study need to be instituted. Via operant

conditioning, behaviorists have shown that techniques of positive reinforcement shape

the repertoire of individual behaviors (Skinner, 1957). Simple reinforcement of

mother/infant communication can alter the verbal behaviors such as those observed in

this study. Reinforcement was an integral facet of the parent training in this study.

Parent Training

Bug-in-the-ear feedback as a vehicle for parent training is an innovative and current

approach to adolescent parent training. All three participants were accepting and

comfortable using the ear phone device and intrigued by the use of technology in parent

training. This came as no surprise since today's adolescents are responsive and thrive on

their visual and auditory senses to learn (Seel, 1997). One participant stated "this is just

like talking on a cell about my baby...its cool."









However, the first two participants' target behavior only improved marginally in

the first intervention phase. During this phase of the study, reinforcement was randomly

given to randomly interjected prompts to participants to exhibit target behaviors. This

intervention format resulted in a subtle change in the frequency of the target behaviors.

Debriefing with the participants revealed that the participants needed more structure in

their prompting, needed to be reinforced after the exhibition of each target behavior and

required simplified language. This resulted in the creation of a modified intervention

which was instituted in all three participants and was quite successful in improving the

exhibition and frequency of target behaviors.

This was a very interesting and important aspect to the study principally because

the original intervention had been pilot tested and was successful on a participant who

was not part of the study. However, she was anl8 year-old college freshman who was

very different from the participants of the study. This variable was difficult to control

because of the Investigator's inability to control the characteristics of the participants

who were recruited for the study.

Recruiting for the Study

Recruiting and retaining participants in this study was very challenging. The plan

initially was to recruit participants through primary care providers in the

Tallahassee/Quincy area. After a nine-month recruiting effort, no participants were

interested in participating in the study. Thus, Florida Department of Health Institutional

Review Board approval was sought to include Capital Area Healthy Start and Gadsden

County Healthy Start as sites for recruiting. Recruiting efforts were a lot more successful

at these sites. It was very important to work closely with the Social Workers who were

involved with the participants and who functioned as the referral sources.









A total of 8 participant referrals were received. Two potential participants declined

participation after receiving information on the study. Six participants were involved in

the study at some point but 3 did not complete their participation due to an array of

reasons. The participants who dropped out of the study were all between 17 and 18 years

old, and most were concerned about being videotaped and paranoid about the possibility

of others having access to the videotape. The key to retaining the participants in the study

was establishing a good rapport with the participants' mothers and maintaining friendly

phone contact. It was easier to establish this rapport with the mothers who were

supportive of their daughters' participation in the study. It was very interesting that all

three participants who were retained until the completion of the study had mothers who

themselves were teenage mothers. The attrition rate is considered as one of the limitations

of the study.

Limitations of the Study and Recommendations

Several limitations of the study that suggest avenues for future research warrant

comment. These limitations are presented below, including recommendations for future

research.

* Only three adolescent mother/infant dyads participated in this study. It would be
worthwhile to replicate this work with a larger sample.

* The three adolescent mother/infant dyads in this study were all African American
and of similar socio-cultural backgrounds. It would be beneficial if future research
was conducted on participants from a different race and socio-cultural
backgrounds. Comparisons could provide valuable information on whether race
and culture influence adolescent mother/infant interaction behaviors.

* The Investigator videotaped mother/infant interaction in the family's home during
each home visit. Although the Investigator waited in another room while the
videotaping occurred, there is no information regarding what effect if any, the
Investigator's presence in the home may have had on the participants' behavior.









* As a result of the risk of attrition, phases of this study were not prolonged.
However, it cannot be assumed that the intervention implemented in the
intervention phases was comprehensive enough to maintain long- term optimal
mother/infant interaction behaviors. Thus, a solution would be to extend the
intervention phases. Additionally, further research is needed to determine the
amount of parent training that is required to maintain optimal mother/infant
interactions in the adolescent mother/infant dyad.

* One of the sub items of the NCAST Feeding Scale was eliminated from the final
analysis of the study due to poor inter-observer reliability. Another sub item
behavior emerged to be difficult to exhibit in the mother who formula feeds her
infant. It is therefore imperative that further research is conducted to explore the
reliability of the sub items of the NCAST Feeding scale especially for formula fed
infants.

* Finally, it would be interesting to explore the reasons why some mothers were
interested and supportive of their daughters' participation in the study and while
other mothers were not. This information will be invaluable in understanding the
social needs of the families of the adolescent mother and also could provide a guide
in recruiting adolescent mothers for future studies.

Implications for Nursing Practice

The findings of this study demonstrated that a prompting intervention using a

bug-in-the-ear feedback can increase the frequency of target attachment behaviors in

the adolescent mother/ infant dyad which according to the literature can ultimately have

a positive impact on the infant's development. Although the intervention was

successful in this study, it is important to indicate that the bug-in-the-ear-feedback

intervention was a labor intensive approach in changing mother/infant interaction

behaviors. Yet it can not be assumed that the intervention implemented in the

intervention phases was comprehensive enough to maintain long term optimal

mother/infant interaction behaviors.

Thus, further nursing research is warranted on exploring the best approaches

in changing these rather complex and difficult behaviors. Since adolescents respond

well to technology, further nursing research can explore how technological approaches









such as tele-health or computerized prompting can be used as a large scale intervention

approach to improve interaction behaviors between the adolescent mother and her

infant.

Nurses are at the front line and can play significant roles in promoting

interaction behaviors in the adolescent mother/infant dyad. Good assessment or

obtaining a baseline of behavior is an important step in the nursing process as well as

being an imperative phase in effecting change. Nurses must be able to identify

individual family needs, set goals in collaboration with the family and modify effective

intervention strategies such as parent training to match the identified needs of

individual mothers while maintaining the essential components of the intervention for

reaching the desired outcome of self efficacy in the young mother.

The implications for nursing practice are important because the application of

research to practice is significant in expanding the knowledge base of nursing practice

related to mother/infant interactions. Unfortunately, there is a clear deficiency of

evidence-based practice in the context of mother/infant interactions. To illustrate,

postpartum/newborn printed discharge instructions from eight different hospitals across

the country were recently reviewed. None of these documents addressed the issue of the

importance of mother/infant communication and its effects on child development

despite the empirical evidence available in the nursing literature. It is also important to

note that all three participants in this study reported that they did not realize the

importance of mother/infant communication.

Hopefully, findings from this study will illuminate and make current the

importance of adolescent mother/infant interactions, particularly as they relate to









communication and infant development. In light of the current managed care era and the

emphasis on health promotion and disease prevention, nurses who work with families of

young children are charged with identifying and implementing effective early

intervention strategies that promote positive parent- child interactions to prevent any

possible long term cognitive sequel a in children of adolescent mothers. At present, most

hospitals have a number of education materials available to patients through visual

technology, computers and in print. It is imperative that nurses and other health care

providers stress the importance of optimal mother/infant interactions in their patient

education curriculum. Additionally, since patient education alone may not be adequate in

changing mother/infant interactions, other avenues of intervening need to be considered.

Furthermore, as demonstrated in this study, the approach of the interventions should be

able to engage the adolescent consumer in order to ensure effective learning.














APPENDIX
INFORMED CONSENT


IRB #


Informed Consent to Participate in Research


If you are a parent, 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
in this study. Therefore, for the rest of the form, the word "you" refers to your child.

You are being asked to take part in a research study. This form provides you with
information about the study and how your privacy will be protected. The Principal
Investigator (the person in charge of this research) or a representative of the Principal
Investigator will also describe this study to you and answer all of your questions. Your
participation is entirely voluntary. Before you decide whether or not to take part, read the
information below and ask questions about anything you do not understand. If you
choose not to participate in this study you will not be penalized or lose any benefits to
which you would otherwise be entitled.


1. Name of Participant ("Study Subject")





2. Title of Research Study

Effect of Bug-in- the-Ear feedback as an Intervention to Promote Attachment Behaviors
in the Adolescent Mother /Infant Dyad.











3. Principal Investigator and Telephone Number(s)

Afua Ottie Arhin, MSN, RN
850-656-0358 (Home)
850-556-6613 (Mobile)


4. Source of Funding or Other Material Support

University of Florida
Florida Nurses Foundation

5. What is the purpose of this research study?

The purpose of this study is find out if a wireless headphone can be used to help teach
young mothers how to take care of their infants.

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

In the first phase of the study, you will be videotaped as you feed your baby formula at
home. This part of the study will last two weeks up to a maximum of four weeks and will
involve two or more home visits by the Researcher You and your baby will be
videotaped only during the home visits. Each visit will last approximately ninety (90)
minutes to 2 hours.
The Researcher will let you know after the first visit if this part of the study will involve
more than the expected two home visits.

The second part of the study is the training phase. You will be asked to wear a wireless
headphone through which you will get instructions on how to help your baby as you feed
him/her. The instructions given will be from a widely used nursing attachment tool
known as the NCAST. This tool has been tested and found to be safe and effective in
similar situations. The instructions will be given by the researcher who is an experienced
mother/baby RN. Examples of instructions would be "hold your baby closer" or "change
your baby's position."

During this part of the study the researcher will visit your home once a week for three
weeks.
Each visit will last approximately 2 hours. Like before, you and your baby will be
videotaped.

As a follow up, three weeks and four weeks after the training, you and your baby will be
videotaped again in your home as you feed. Each of these two visits will last
approximately ninety (90) minutes.









During the videotaping, the camcorder will be set up on a tripod in the room you will be
feeding your baby in. The Researcher will not always be present in the room. Using the
well-known nursing tool, the videotape will be coded by research assistants at a later time
to measure you and your baby's interaction. If you have any questions now or at any time
during the study, you may contact the Principal Investigator listed in #3 of this form.

You and your family will have the opportunity to review the videotapes throughout the
study.
All videotapes will be stored in a locked cabinet in the researcher's office during the time
the study is being conducted. When the study is completed all videotapes will be
destroyed.


7. If you choose to participate in this study, how long will you be expected to
participate in the research?

The first part (before you get training with the headphone) will last two weeks up to a
maximum of four weeks and includes two sessions or more. The training part will last
about three weeks and will include three sessions. As a follow up, three and four weeks
after the training you and your baby will be videotaped again

Each session will last approximately ninety minutes to 2 hours. The whole study should
take no more than nine weeks, or a total of eighteen 18 hours.

8. How many people are expected to participate in this research?

Six adolescent mothers and their infants will be enrolled in the research. Three adolescent
mothers and their infants will be expected to participate in the entire research from start
to finish.



9. What are the possible discomforts and risks?

You may have some minor discomfort knowing that you are being videotaped and having
to wear a wireless headphone while feeding your infant. There are no identified risks
associated with this study.

Throughout the study, the researchers will notify you of new information that may
become available and might affect your decision to remain in the study.

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









lOa.What are the possible benefits to you?

You may or may not personally benefit from participating in this study. If the parent
training interventions are shown to help how you and your baby interact, then you would
directly benefit. You will also get important information that you can use in helping your
baby and how he/she grows and develops.


lOb. What are the possible benefits to others?

If the parent training has a good effect, then this method can be used to help other
adolescent mothers in their interactions with their infants.


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

No, this study will not cost you anything.


12. Will you receive compensation for taking part in this research study?

You will receive $4.00 towards gift certificates to Wal-Mart for each completed session
up to a maximum of nine sessions.

13. 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 will
be provided without charge. However, hospital expenses will have to be paid by you or
your insurance provider. No other compensation is offered. Please contact the Principal
Investigator listed in Item 3 of this form if you experience an injury or have any questions
about any discomforts that you experience while participating in this study.



14. What other options or treatments are available if you do not want to be in this
study?

The option to taking part in this study is not to take part in this study. If you do not want
to take part in this study, tell the Principal Investigator or her assistant and do not sign
this Informed Consent Form.


15a. Can you withdraw from this research study?

You are free to withdraw your consent and to stop participating in this research study at









any time. If you do withdraw your consent, there will be no penalty, and you will not
lose any benefits you are entitled to.

If you decide to withdraw your consent to participate in this research study for any
reason, you should contact Afua O. Arhin at (850)656-0358 or (850) 561-2874.

If you have any questions regarding your rights as a research subject, you may phone the
Institutional Review Board (IRB) office at (352) 846-1494 or the Florida Department of
Health,
Institutional Review Board at 850-245-4585 or toll free in Florida at 1-866 433-2775.


15b. If you withdraw, can information about you still be used and/or collected?

If you withdraw no more data about you will be collected. However, information that was
gathered before you withdrew may be analyzed.


15c. Can the Principal Investigator withdraw you from this research study?

You may be withdrawn from the study without your consent for the following reasons:

If home visit appointments are not kept on more than three occasions.
If Principal Investigator feels threatened in the home environment.


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

Information collected about you and/or your baby will be stored in locked filing cabinets
or in computers with security passwords. Only certain people have the legal right to
review these research records, and they will protect the secrecy (confidentiality) of these
records as much as the law allows. These people include the researchers for this study,
certain University of Florida officials, the hospital or clinic (if any) involved in this
research, and the Institutional Review Board of University of Florida and the Florida
Department of Health (IRB; an IRB is a group of people who are responsible for looking
after the rights and welfare of people taking part in research). Otherwise your research
records will not be released without your permission 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.









17. How will the researchers) benefit from your being in this study?

In general, presenting research results helps the career of a scientist. Therefore, the
Principal Investigator may benefit if the results of this study are presented at scientific
meetings or in scientific journals.

18. Will I know the results of this study?

Yes, all participants will be informed in writing the findings of the study when
completed. Again, your identity will not be disclosed

Signatures

As a representative of this study, I have explained to the participant or the participant's
legally authorized representative the purpose, the procedures, the possible benefits, and
the risks of this research study; the alternatives to being in the study; and how privacy
will be protected.



Signature of Person Obtaining Consent Date

Consenting Adults. I have been informed about this study's purpose, procedures,
possible benefits, and risks; the alternatives to being in the study; and how my (or the
participant's) privacy will be protected. I have received a copy of this Informed Consent
Form. I will be given the opportunity to ask questions before I sign, and I have been told
that I can ask other questions at any time.



Adult Consenting for Self. By signing this form, I voluntarily agree to participate in
this study. By signing this form, I am not waiving any of my legal rights.


Signature of Adult Consenting for Self


Date









Parental Consent Forms for Adolescents 18 years or Less
Signatures

As a representative of this study, I have explained to the participant or the participant's
legally authorized representative the purpose, the procedures, the possible benefits, and
the risks of this research study; the alternatives to being in the study; and how privacy
will be protected.


Signature of Person Obtaining Consent Date


Consenting Adults. You (and/or the participant) have been informed about this study's
purpose, procedures, possible benefits, and risks; the alternatives to being in the study;
and how your (or the participant's) privacy will be protected. You have received a copy
of this Informed Consent 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.



Parent/Adult Legally Representing the Subject. By signing this form, you voluntarily
give your permission for the person named below to participate in this study. You are not
waiving any legal rights for yourself or the person you are legally representing. After
your signature, please print your name and your relationship to the subject.


Signature of Parent/Legal Representative (for Minor Mother) Date


Print: Name of Legal Representative of and Relationship to Participant:


Signature of Parent/Legal Representative (for Child)


Date









Adolescent Assent Form

The purpose of this study is to learn the effects of a wireless head phone as a parent
training intervention on interaction behaviors between the adolescent mother and her
infant

You will first be videotaped as you feed your baby formula at home. This part of the
study will last three weeks and will involve three home visits by the Investigator.
The second part of the study is the training phase. You will be asked to wear a wireless
headphone through which you will get instructions on how to help your baby as you feed
him/her. This part of the study will last three weeks and will involve three home visits by
the Investigator. Like before, you and your baby will be videotaped.
As a follow up, three weeks and four weeks after the training, you and your baby will be
videotaped again in your home as you feed.

Although legally you cannot "consent" to be in this study, we need to know if you want
to take part. If you decide to take part in this study, and your parent or the person legally
responsible for you gives permission, you both need to sign. Your signing below means
that you agree to take part (assent). The signature of your parent/legal representative
above means he or she gives permission (consent) for you to take part.

Please check one of the following boxes:

D No, I do not want to take part in this study


D Yes, I want to take part in this study





Assent Signature of Participant Date


Signatures

As a representative of this study, I have explained to the participant or the participant's
legally authorized representative the purpose, the procedures, the possible benefits, and
the risks of this research study; the alternatives to being in the study; and how privacy
will be protected.


Signature of Person Obtaining Consent


Date
















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BIOGRAPHICAL SKETCH

Afua Arhin received a Bachelor of Science in Nursing from University of Ghana in

West Africa and a Master of Science in Nursing from University of Wisconsin in

Madison. Her research interests are in adolescent sexuality and parenting, learning styles

and single subject methodology. She is an Assistant Professor at Florida A & M

University in Tallahassee.




Full Text

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EFFECT OF BUG-IN-THE-EAR-FEEDBACK AS AN INTERVENTION TO PROMOTE ATTACHMENT BEHAVI ORS IN THE ADOLESCENT MOTHER/INFANT DYAD By AFUA OTTIE ARHIN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005

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This document is dedicated to my children, Kofi and Stephanie.

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ACKNOWLEDGMENTS Endeavors such as this study are most ofte n aided in both direct and subtle ways by numerous people. It is my opportunity here to give thanks to those who have made this dissertation a rewarding, edu cational experience. Unfortuna tely, written words may not reflect the magnitude of the debt of thanks which is owed each person. My thanks begin with my parents, Mr. Ottie and the deceased Mrs. Grace Ottie, to whom can be attributed much of my interest in learning. The encouragement given by Dr. Jennifer Elder shall not be forgotten. It will in fact be difficult to ever repay this lady, friend and scholar for her investment in my personal development. The same is true for Dr. Jon Bailey for his tutoring, encouragement and thoughtful critique of this manuscript. I would like to thank Dr. Bruce Thyer fo r his encouragement and tireless efforts especially in having me successfully coauthor with him my very first book chapter. I would also like to thank Dr. Terry Mills for his persistence and guidance in helping me with manuscript development and publication. I would like to express my gratitude to Dr. Sharleen Simpson for her invaluable feedback and support. The mothers who participated in this st udy and their families must most certainly be thanked for their cooperation. The staff of Capital Area and Gadsden County Healthy Start must be thanked for their cooperation a nd support in my recruiting efforts. I would also like to thank Florida Nurses Foundation for the dissertation grant award that partly funded this study. iii

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And in the end, I suppose the single great est thanks goes to my husband, Kwame, and my children, Kofi and Stephanie. I am indebted to them for their patience, love and encouragement and hope they see in this work, parts of their positive influence. iv

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TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................iii LIST OF TABLES ...........................................................................................................viii LIST OF FIGURES ...........................................................................................................ix ABSTRACT .........................................................................................................................x CHAPTER 1 ATTACHMENT THEORY..........................................................................................1 Defining Attachment....................................................................................................1 Attachment in Adolescent Mothers ..............................................................................2 Ethological Theory .......................................................................................................2 Function of Imprinting and Innate Signaling in Parent-Infant Bonding ...............3 Defining Affectional Bonds ..................................................................................3 Studies of Affectional Mother -Infant Bonds in Adolescents ................................4 Behavioral Approach a nd Learned Helplessness .........................................................5 Defining the Dependency and Drive Reduction Model ........................................5 Importance of Early Relationship Experiences .....................................................5 Learned Helplessness ............................................................................................6 Interventions to Counter the Deve lopment of Learned Helplessness ...................7 Family Stress Model .....................................................................................................8 Defining the Family Stress Model.........................................................................8 ABCX Theory of Family Stress ............................................................................8 Applying Family Stress Theory to Adolescent Mothers and Infants ....................9 Parent Training Paradigm ...........................................................................................10 Contribution of Self -Efficacy and Social Learning Theory ......................................10 Incorporation of Behavioral Pr inciples in Parent Training .................................12 Nursing Theory and the Nursing Meta-paradigm .......................................................13 Kings Theory of Goal Attainment......................................................................13 Congruence of Kings Theory with Banduras Self Efficacy Theory .................14 Implications for Nursing Practice ...............................................................................15 Summary ..............................................................................................................15 Statement of Purpose ..................................................................................................17 v

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2 REVIEW OF THE LITERATURE............................................................................18 Importance of Mother Infant Interaction .................................................................18 Importance of interventions in adolescent mothers .............................................18 Review of Intervention Literature in the Adolescent /Mother Infant Dyad ........19 Bug-in-the-ear feedback (BITE) ..........................................................................21 Single Subject Design ..........................................................................................22 3 METHODOLOGY.....................................................................................................24 Participants and Setting ..............................................................................................24 Pilot Testing .........................................................................................................25 Participant 1 .........................................................................................................25 Infant 1 .................................................................................................................26 Participant 2 .........................................................................................................26 Infant 2 .................................................................................................................26 Participant 3 .........................................................................................................26 Infant 3 .................................................................................................................27 Procedures ...........................................................................................................27 Experimental Procedure ......................................................................................27 Baseline Phase .....................................................................................................28 Intervention ..........................................................................................................29 Instruments for Evaluating Dependent Variables .......................................................29 NCAST ................................................................................................................29 Operational Definitions ..............................................................................................31 Independent Variables.........................................................................................31 Inter-observer Reliability .....................................................................................33 Data Analysis ..............................................................................................................34 4 RESULTS...................................................................................................................36 Findings ......................................................................................................................36 Sensitivity to Cues ......................................................................................................36 Participant 1 .........................................................................................................37 Participant 2 .........................................................................................................38 Participant 3 .........................................................................................................38 Social-Emotional Growth Fostering ...........................................................................38 Participant 1 .........................................................................................................39 Participant 2 .........................................................................................................40 Participant 3 .........................................................................................................40 Cognitive Growth Fostering .......................................................................................43 Participant 1 .........................................................................................................43 Participant 2 .........................................................................................................43 Participant 3 .........................................................................................................44 Childs Clarity of Cues ...............................................................................................44 Childs Response to Mother .......................................................................................47 Infant 1 .................................................................................................................47 vi

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Infant 2 .................................................................................................................49 Infant 3 .................................................................................................................49 Summary of Findings ..........................................................................................51 5 DISCUSSION.............................................................................................................53 Overview .....................................................................................................................53 Participant Characteris tics and Behaviors ..................................................................54 Parent Training ...........................................................................................................56 Recruiting for the Study ..............................................................................................57 Limitations of the Study and Recommendations ........................................................58 Implications for Nursing Practice ...............................................................................59 APPENDIX INFORMED CONSENT.............................................................................62 LIST OF REFERENCES ...................................................................................................70 BIOGRAPHICAL SKETCH .............................................................................................77 vii

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LIST OF TABLES Table page 3-1 Videotaping Schedule of Participants ......................................................................28 3-2 Inter-observer Reliability .........................................................................................34 4-1 Sensitivity to Cues: Frequency of In fants Head Higher than Mothers Hips .........37 4-2 Sensitivity to Cues: Frequency of Mother Maintaining Trunk to Trunk Position ...37 4-3 SocialEmotional Growth Fosteri ng. Frequency of Mother Maintaining Enface Position .....................................................................................................................39 4-4 Childs Clarity of Cues-Builds up Tension ..............................................................44 4 Childs Clarity of Cues-Decrease in Tension ...........................................................45 viii

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LIST OF FIGURES Figure page 4-1 Frequency of mothers comments on infants hunger during baseline and intervention phases ...................................................................................................41 4-2 Frequency of mothers smiles and use of positive statements during baseline and intervention phases ...................................................................................................42 4-3 Frequency of mothers exhibiting cognitiv e growth behaviors during baseline and intervention phases ...................................................................................................46 4-4 Infant 1 Frequency of infant looking in mothers direction .....................................47 4-5 Relationship between Infant 1 looking in mothers direction and target behaviors during baseline and intervention phases...................................................................48 4-6 Infant 2 Frequency of infant looking in mothers direction .....................................49 4-7 Relationship between Infant 2 looking in mothers direction and target behaviors during baseline and intervention phases...................................................................50 4-8 Infant 3 Frequency of infant looking in mothers direction .....................................51 4-9 Relationship between Infant 3 looking in mothers direction and target behaviors during baseline and intervention phases...................................................................52 ix

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy EFFECT OF BUG-IN-THE-EAR-FEEDBACK AS AN INTERVENTION TO PROMOTE ATTACHMENT BEHAVI ORS IN THE ADOLESCENT MOTHER/INFANT DYAD By Afua Ottie Arhin December 2005 Chair: Jennifer Elder Major Department: Nursing Background: Previous studies have shown that compared with adult mothers, adolescent mothers are less verbally and emotionally responsive, show less positive affect, and have less intense emotional and beha vioral attachment interactions with their children. These less than optimal adolescent mo ther/infant attachment interactions have been found to affect the childs he althy growth and development. Objectives: The study aimed to identif y and characterize the frequency of attachment behaviors exhibi ted in the infant/adolescent mother dyad and obtain a baseline of the frequency of the interact ion on the NCAST Feeding Scale. The second aim was to implement an individualized bug-in -the-ear feedback parent training model to improve the frequency and quality of infant-mother interaction and assess its efficacy using the NCAST Feeding Scale. The third ai m was to compare mother/infant attachment behavior frequencies pre and post training. x

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Methods: A non-concurrent multiple baseli ne design across three participants was used. Baseline videotaping was done at the hom e of three 15-year old African American mothers as they formula fed their infants w ho were between the ages of 11/2 to 51/2months. The baseline sessions were repeat ed until a stable baseline of interaction behaviors was achieved. The individualized intervention using a bug-in-the-ear feedback was instituted based on the occurrence or nonoccurrence of target behaviors that were identified using the NCAST Feeding Scale. Results: The baseline phase of the study clearly identified low frequency and nonoccurrence of attachment behaviors of the verbal/communication type. After the intervention was instituted in the second phase of the study th ere were positive effects in the mothers behaviors which in turn positively impacted infant behavior. This was particularly notable in the area of the child responding to the mother. Conclusion: Findings from this study exte nd and strengthen previous research in this area that has shown that adolescent mother s are less verbal to their infants. Although the intervention was successful in this study, it is important to indicate that the bug-inthe-ear feedback intervention was a labor in tensive approach in changing mother/infant interaction behaviors. Thus, further nursing research is warranted on exploring the best approaches in changing these rather complex and difficult behaviors. xi

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CHAPTER 1 ATTACHMENT THEORY Defining Attachment Attachment in humans refers to an affectional tie that one person forms with another specific individual. Th e first individual is most likely the mother and attachment tends to endure (Ainsworth, 1989). Through theoretical developments of John Bowlby and Mary Ainsworth, a rich knowledge base of attachment has emerged which emphasizes the importance of the infants security. According to Bowlby (1982), the pathway followed by each developing individu al and the extent to which he or she becomes resilient to stressful life events is determined to a very significant degree by the pattern of attachment developed during th e early years. Subseq uent studies have confirmed that a mothers attachment to her infant is a major contributor to the childs healthy growth and development (Ainsworth, 1989). Attachment in Bowlbys framework is the bio-behavioral process that leads from distress to solace, from real or perceived da nger to felt safety. It can be defined as proximity seeking, comfort-seeking, and security-seeking in situa tions of real or perceived threat of danger. The ability of th e mother and the infant to communicate is a delicate yet necessary element in a good relationship. Moth ers use various sensorimotor means to interact with an infant. Touch a nd visual contact are the most powerful means of communicating with an infant (Brazel ton & Cramer, 1990). Crying, smiling, grasping, reaching out and establishing visual contact are among the attachment behaviors that infants display to maintain proximity with their parents and express their needs. 1

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2 Attachment in Adolescent Mothers Adolescent mothers may be at high risk for negative parent child interactions. Studies have shown that compared with adult mothers, adolescent mothers are less verbally and emotionally responsive, show less positive affect, and have less intense emotional and behavioral involvement with their children (Christopher, Bauman & VenessMeehan, 1999). There is much evidence in the literature suggesting that adolescent mothers are at risk for adverse ps ychological and behavior al problems that can affect the mothers life course as well as the infants health and development. Adolescent mothers have displayed higher levels of pare nting stress and are less responsive and less sensitive in interactions w ith their infants than adult mothers (Passino et al., 1993). Further, adolescent mothers may be less co mpetent to parent in terms of their emotional development, parenting experience, and parenting skills (Furstenberg, BrooksGunn, Chase-Lansdale, 1989). Consequently, ch ildren of adolescent mothers have been found to suffer more physical, intellectua l and emotional difficulties. Disturbed attachments have been implicated in the development of dysfunctional parent-child relationships (Koniak-Griffin, 1988) and other negative outcomes. Since adolescents are responsible for almost 500,000 births in the United States annually (Ventura, Martin, Curtin & Matthews, 1998), and there appears to be such an ominous impact of this phenomenon on the infant and his or her long term outcome, it is imperative that this public health problem is closely analyzed. Ethological Theory Ethology is concerned with the adaptive, or survival, value of behavior and its evolutionary history (Hinde, 1988). This theoretical orientation was first applied to research on children in the 1960s, but has become more influential in recent years. The

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3 origins of ethology can be traced to the work of Darwin. Its modern foundations were laid by two European zoologists, Lorenz a nd Tinbergen (Dewsbury, 1992). Watching the behaviors of animal species in their natu ral habitats, Lorenz and Tinbergen observed behavioral patterns that promote survival. The most well known of these is imprinting, the early following behavior of baby geese that ensures that the young will stay close to the mother, be fed, and protected from da nger. From the ethological perspective, attachment is an innate human survival mechanism. Function of Imprinting and Innate Signaling in Parent-Infant Bonding Bowlby (1969), who first applied this id ea to the infant-caregiver bond, was inspired by Lorenz's studies of geese imprinting. He believed that the human baby, like the young of most animal species, is equipped with a set of built-in behaviors that helps keep the parent nearby, increasing the chances that the infant will be protected from danger. Contact with the parent also ensure s that the baby will be fed, but Bowlby was careful to point out that feeding is not the basis of attachment. According to Bowlby, the infant's relationship to the parent begins as a set of innate signals that call the adult to the baby's side. As time pa sses, a true affectionate bond develops, which is supported by new cognitive and emotional capacities as well as a history of consistent and sensitive, responsive care by the pa rent. Out of this experience, children form an enduring affec tional bond with their caregivers. This enables the child to use this attachment figure as a secu re base across time and distance. Defining Affectional Bonds Affectional bonds are formed as a result of reinforcing inte ractions with the attachment figure and the chil d. Emotional life is seen as dependent on the formation, maintenance, disruption or renewal of a ttachment relationships. Consequently, the

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4 psychology and psychopathology of emotion ar e deemed to be largely the psychology and psychopathology of affectional bonds. Th e fundamental assumption in attachment research on human infants is that sensitive re sponding by the parent to the infant's needs results in an infant who demonstrates secure attachment, while lack of such sensitive responding results in insecure attachment (Lamb, Thom pson, Gardner & Charnov, 1985). Theorists have postulated several varieties of insecure attachment. Ainsworth et al. originally proposed two: avoi dant, and resistant also cal led ambivalent (Ainsworth, Blehar, Waters, & Wall, 1978). The work of Klaus and Kennell (1976) on maternal bonding had a great impact on nursing practice. Maternity and neonatal hospital settings were modified to promote early and extensive contact between mothers and th eir newborn infants in order to promote attachment. However, this hypothesis of a cr itical period has been challenged by other studies (Gay, 1981; Rubin, 1984). Given the cont radictory findings early contact cannot be used as the sole marker on which mother /infant attachment is evaluated, even though beneficial effects have been reported. Attachment can also be evaluated in periods past the immediate postpartum period. Studies of Affectional MotherInfant Bonds in Adolescents It has been suggested in th e literature that adolescent mothers by virtue of their immaturity have difficulty establishing optimal interactions with their infants. In a study conducted in the University of Pittsburgh, thir ty-eight full-term, first-born infants of adolescent mothers were assessed at six m onths of age in a standardized laboratory setting using a modified Ainsworth Strange Situation procedure (Broussard, 1995). The attachment security rate with in this sample was 23.7%. Attachment security problems were attributed to faulty interaction pattern s between the adolescent mother and infant.

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5 Another study conducted through Oklahoma State University compared adolescent mothers and older mothers interaction patte rns with their six-month-old infants. During feeding, the adolescent mothers demonstrated less expressiveness, less positive attitude, less delight, less positive regar d, fewer vocalizations and a lo wer quality of vocalizations than non adolescent mothers. During play, the adolescent mother s demonstrated less inventiveness, patience and positive attitude (Culp, Culp, Osofsky & Osofsky, 1991). Behavioral Approach a nd Learned Helplessness Defining the Dependency and Drive Reduction Model The behavioral approach of attachment is based on the dependency and drive reduction model. Dependency is viewed as an acquired drive originating because the helpless infant is dependant on his mother for gratification of his basic physiologic needs (Sroufe, Duggal, Weinfield & Carlso n, 2000). The crying and other behaviors characteristic of the infant are reinforced through his/her mothe rs nurturing actions, making them more likely to occur again. The stimulus provided by the mothers face and presence signals impending gratification. This is how the infant acquires a drive to be close to his/her mother and seek her atte ntion. This dependency drive is eventually generalized to other people in the childs life. By the second half-year, an infant exhib its purposeful goal directed behavior. (Sroufe, Duggal, Weinfield & Carlson, 2000). Infa nts behave in order to elicit a particular response from the mother such as raising arms to indicate a desire to be picked up. At this point, the infant actively participat es in the regula tion process. Importance of Early Relationship Experiences Early relationship experiences are vital becau se they are the first models of patterns of self-regulation. Infants genera lize to what they experience. If they learn that they can

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6 turn to others when in need and get responses they will believe in their own effectiveness in maintaining regulation. Also because their needs are routinely met, they will believe in their self worth .A sense of personal effectiveness follows from routinely having ones actions achieve their purposes. These positive expectations towards others as well as selfconfidence are logical outcomes of experienci ng routinely responsive care. This provides an important foundation for later self-regulat ion (Sroufe, Duggal, Weinfield & Carlson, 2000). Learned Helplessness When care is chaotic, inconsistent or rejecting such as in highrisk mothers including adolescents, an anxi ous attachment relationship may evolve. In the face of inconsistency, the infant may maximize the ex pression of attachment behaviors, emitting high intensity signals such as inconsolable cr ying, or alternatively may learn to cut off expression or attachment behaviors (Sr oufe, Duggal, Weinfield & Carlson, 2000). This strategy is consistent with the theory of learned helplessness. Learned helplessness occurs when a pers on cannot control outcomes. Mark (1983) defines this as an adaptive response to s ituational demands. It is further explained by Seligman (1975), who developed the concept as the reduction of efforts and motivation after an individuals efforts have little or no impact on the outcome. In the most extreme form of this condition, the person does not try to initiate anything. The effects of learned helplessness are experienced in one or more of the following domains: motivational, affective and cognitive (Abram son, Seligman & Teasdale, 1978). In a recent study examining the concept of learned helplessness, prenatal characteristics including cognitive readine ss for parenting, intelligence and personal adjustment of 121 adolescent mothers were examined and correlated with the behavior

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7 outcomes of their children (Sommers et al., 2000). The findings i ndicated that by age 3, many of the children were at high risk for atypical and pe rhaps dysfunctional development. Less than 30% of the sample wh ich was generally healthy at birth showed normal cognitive development, emotional functioning and adaptive behavior at 3 years of age. The learned helplessness model provide s a possible explanati on for the behaviors that are seen in these children. It may be that for children who have rarely been successful with interacting with their mothers, withdrawal is an effective self defense mechanism protecting them from greater failure. Interventions to Counter the Development of Learned Helplessness On a positive note, it may be possible that many learned helplessnes. Risk factors can be reduced by instituting in tervention programs to facilitate the development of an early, successful attachment bond between th e adolescent mother and her infant. One example of such an intervention is that of Field (1998) who investigated 40 full term 1 to 3 month old infants born to depressed adoles cent mothers who were low socioeconomic status and single parents. The infants were given 15 minutes of either massage or rocking for 2 days per week for a 6-week period. A co mparison of infants in the massage therapy group with infants in a rocking control gr oup showed that the massaged infants spent more time in active alert and awake states and cried less. Over the 6-week period, the massaged infants gained more weight and showed greater improvement on emotionality, sociability and soothability. There were also decreases in stress hormones. These results suggest that actively engaging infants may have a positive effect on the overall well being of the child.

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8 Family Stress Model Defining the Family Stress Model Another theoretical approach that could be used in explaining less than optimal attachment in the adolescent motherinfant dyad is the family stress theory. Family stress theory postulates that acute stressors when accumulated could lead to family crises, including physical, emotional, or relational crises (McDonald, 1999). ABCX Theory of Family Stress Hill's (1971) theory of family stress wa s formulated after the Great Depression, based on extensive observations of families who survived contrasted with those whose families did not. As Hill interviewed familie s who had lost their jobs and were existing in extreme poverty, he looked for factors whic h contributed to family survival of these circumstances. From these qualitative data, Hill theorized that there are two complex variables that act to buffer the family from acute stressors and reduce the direct correlation between multiple stressors and family crisis. These were formulated into what he called his ABCX theory of family stress. The A variable is the stressful event; th e B variable refers to the complex of internal and external family resources and so cial support available to the family, i.e., the social connectedness within the family, as well as social conn ectedness outside the family. Hill theorized that social isolation w ould significantly increase the impact of the multiple stresses on the family functioning. In contrast, positive social supports would minimize the impact. Hill's "C" variable, the perception factor, was the second predictor of the extensiveness of the im pact of stress on the family.

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9 Applying Family Stress Theory to Adolescent Mothers and Infants Applied to the adolescent mother/infant dyad, this theory suggests that families with poor resources, who perceive the pregnanc y as a crisis, may have poor mother-infant interactions and function at lower levels. Af ter a period of reorganization, families with higher cognitive appraisals a nd support are able to regroup and operate at a higher than baseline level while families with poor suppor t and lower cognitive appr aisals continue to function at a lower level. Family stress theory, when applied to attachment behaviors of the adolescent mother-infant dyad, clearly underscores the importance of so cial support and how nursing could play a vital role in promoting the we ll being of the adolescen t mother-infant dyad. This could be in the form of providing so cial support throughout the pregnancy or the initiation of prevention programs. There are documented studies that have shown the clear benefits of early prenatal involvement by community nurses in high risk mothers (Darmstadt, 1990). Adopting the attachment paradigm as a framework for early intervention and primary prevention in the adolescent mothe r-infant dyad has tremendous nursing practice implications. The literature suggests that th e experimenter-mother interaction provides emotional support for the mothers participati ng in intervention programs and that such support is an important variable enhancing th e quality of maternal behavior (Kelly & Barnard, 2000). Further, several researchers have sugge sted that professionals intervention behaviors could serve as models for mother-child interaction behaviors. However, there is little information on the be st conditions of interv ention and its effect on later development. It is evident from the preceding theoretical review that effective mother-infant interaction may be compromi sed in the adolescent mother/infant dyad,

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10 leading to negative outcomes in the child. It is therefore imperative that effective interventions such as parent training are established to help improve the long-term outcomes of these children. Parent Training Paradigm The birth of a child is a very emotiona l time for mothers who may experience a wide range of emotions from joy and exciteme nt to frustration and disappointment. While such emotions come naturally, knowledge and sk ills related to parent ing are less natural. Most studies suggest that beha vioral parent training is an effective early intervention strategy for families with infants (Breismeis ter & Schaefer, 1997). Important components of early intervention are teaching mothers to read and interpret infant cues, effectively manage the infants behavior and to promote positive mother-child interactions. This type of intervention may ultimately prev ent negative outcomes in the child. Contribution of Self -Efficacy and Social Learning Theory Behaviorally focused parent tr aining is a generic term that refers to teaching parents how to become therapeutic change agents for their children (Hoffman, 1998). Parents are provided the appropriate knowledge skills, and incentives to initiate coping efforts and persistence in the face of difficulty in relating to their child. Parent training is designed to offer parents new resources for enhancing their parenting skills (Breismeister & Schaefer, 1997). One of the benefits of the pa rent training approach is that it allows parents to develop a well established sense of mastery and confidence in their parenting skills. This concept of achieving mastery and c onfidence is consistent with Banduras theory of self efficacy. Perceived self-efficacy is defined as people's beliefs about their capabilities to produce designate d levels of performance that exercise influence over

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11 events that affect their live s (Bandura, 1995). A strong sense of efficacy enhances human accomplishment and personal well-being in many ways. People with high assurance in their capabilities approach difficult tasks as challenges to be mastered rather than as threats to be avoided. Such an efficacious outlook fosters intrinsic interest and deep engrossment in activities. Such individuals set themselves challenging goals and maintain strong commitment to them. They heighten and su stain their efforts in the face of failure. These individuals quickly recover their sense of efficacy after failures or setbacks. They attribute failure to insuffic ient effort or deficient knowledge and skills which are acquirable. They approach thre atening situations with assurance that they can exercise control over them. Such an efficacious outlook produces personal accomplishments, reduces stress and lowers vulnerabi lity to depression (Bandura, 1986). The self-efficacy literature suggests that efficacious expectation alone will not produce the desired performance if the com ponent capabilities ar e lacking (Bandura, 1977). People also require the appropriate know ledge, tools, skills, and incentives that can be acquired through learning. Social learning theory has its roots in th e behaviorist notion of human behavior as being determined by learning, particularly as shaped by reinforcem ent in the form of rewards or punishment. This theory is based on early research in behaviorism conducted by Ivan Pavlov, John Watson, and B. F. Skinner. One of the key premises of social learning theory is that the ch ilds behavior, whether adaptive or maladaptive, desirable or undesirable, is in part a product of the childs history and present inte ractions with people and circumstances that impact on the child (Breismeister & Shaefer, 1998).

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12 In the context of promoting attachment be haviors and for an interaction between a mother and child to be effectiv e, the infant and mother must give clear cues to each other. The mother must know how to respond to the infa nts cues and the infant must respond to the mothers cues and the environment must facilitate the interaction that occurs. The interaction becomes a cyclical learning event that either reinforces the behavior that occurs or facilitates its terminati on (Barnard, Morisset & Spieker, 1993). Incorporation of Behavioral Principles in Parent Training Many procedures in parent training can be derived from the general behavioral principles. Early research was patterned in many ways after the style of research developed by Skinner (1957). A fundamental feature of the methodology is the detailed analysis of the behavior of an individual and some type of intervention procedure brought into contact with the target behavior. The sp ecific behavioral parent training procedure is determined by specific problems and needs (Breismeister & Shaeffer, 1997). In the context of the young mother and her infant providing the appropriate knowledge and skills through parent training ma y enhance the reciprocal inter acting abilities of the dyad. Because the innate characteristics of the child are difficult or impossible to alter, interventions practiced to da te for promoting mother child attachment have focused on the mothers behaviors. The goals of these interventions have been to increase competence of the mother in interpreting and responding to the in fants communication cues by alleviating distress and promoting gr owth-fostering behaviors (Barnard, Morisset & Spieker, 1993). The specific parent-training that will be us ed in this study consists of prompting and cueing (antecedent stimulus variables) by the investigator through a wireless earphone. This training approach relies heav ily on Skinners stimulus-response model.

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13 A number of published studies have shown the clear benefits of early intervention programs in facilitating the development of ear ly attachment between mother and child. Meyer and Anderson (1999) reported on an indi vidualized family based intervention that significantly reduced maternal stress and depr ession and enhanced mother-infant feeding interactions. Barnett (1995) identified that the most promising pa rent training programs operate at the level of prev entative and early interventions with identified high risk populations. Intervention programs that were particularly effective focused on changing behavior rather than on changing att itudes and/or feelings (Elder, 1997). Nursing Theory and the Nursing Meta-paradigm Kings Theory of Goal Attainment Imogene Kings (1981) theory of goal attain ment is consistent with selfefficacy and parent training. She defines persons as social beings who are rational, sentient, perceiving, thinking, feeling, able to choose between alternativ e actions, able to set goals [and] select means toward goals. Her meta-p aradigm of the nursing process relies on a conceptual framework of three systems: (a) th e personal, relating to the individual, (b) the interpersonal, involving the in teraction between individuals particularly the nurse and patient, and (c) social, involvi ng the individuals relationshi ps with family and other external systems. It is in the context of this interpersonal system that nurse and patient set goals and evaluate their achievement (Burney, 1991). Parent training of young mother s, by nursing, in the context of Kings theory is the interpersonal system that the nurse and patient set goals and evaluate their achievement. The key to Kings theory is this nurse-patient transaction. The personal system is just as vital to the theory, because it recognizes th e significance of different perceptions of the nurse and patient especially since transactions require perceptual a ccuracy in nurse-client

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14 interactions and congruence between role performance fo r nurse and client (Chinn & Kramer, 1991). King suggests that it is th e capacity of human beings to interact meaningfully with one another in the pursuit of common goals that a llows progress of the patient on all three levels (Aggleton & Ch almers, 2000). Kings theory effectively demonstrates that communicati on, goal setting and attainment are ways to help patients meet their self care needs, one of the main goa ls of nursing. This can be translated to the achievement of selfefficacy. Congruence of Kings Theory with Banduras Self Efficacy Theory According to Bandura (1997), individuals self-efficacy beliefs powerfully influence their attainments. He views people as self-organizing, proa ctive, self -reflecting and self-regulating. From his theoretical perspective, human functioning is viewed as the product of a dynamic interplay of personal, be havioral, and environmental influences. This is the foundation of Bandura's (1986) c onception of reciprocal determinism, the view that (a) personal factors in the form of cognition, affect, and biological events, (b) behavior, and (c) environmental influences create interactions that result in a triadic reciprocity, a framework for self efficacy. It is evident that these two theories, Banduras self efficacy theory and Kings theory of goal attainment, though from different fields and perspectives, are congruent. In Banduras selfefficacy framework, nur sing interventions can be viewed as environmental influences that may effect chan ge. In Kings theory, nursing is part of the interpersonal system. She acknowledges the impo rtance of the nurses role in assessing the environment and making alterations conducive to promoting health.

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15 Implications for Nursing Practice In light of the current managed care era and the emphasis on health promotion and disease prevention, nurses who work with families of young children are charged with identifying and implementing effective early in tervention strategies that promote positive parent-child interactions (E lder, 1995; Tucker et al., 1997). Consistent with Kings nursing meta-par adigm and the preceding theoretical linkages described, it is apparent that good assessment or obt aining a baseline of behavior is an important step in the nursing process as well as being an imperative phase in effecting change. Nurses must be able to iden tify individual family values and needs, set goals in collaboration with the family and modi fy effective intervention strategies such as parent training to match the identified n eeds and goals of individual mothers while maintaining the essential components of the intervention for reaching the desired outcome of self efficacy in the young mother. Summary A mothers attachment to her infant is recognized as a major contributor to the childs healthy growth and development. Att achment theory postulates that certain inborn behaviors such as crying, reaching and smiling in human neonates are exhibited in order to bring a protective, nurtu ring attachment figure into close proximity (Bowlby, 1982). This closeness provides the infant with secu rity and gratification and serves as the blueprint for all later attachment relations hips. Disturbed attachments have been implicated in the developmen t of dysfunctional parent-chi ld relationships and other negative psychosocial outcomes. Although a plethora of resear ch has been done on this subject, very few studies have been conducted in the recent past. Much of the research available for review was

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16 conducted in the 1980s and 1990s. Review of this literature suggests that a disproportionate percentage of insecure at tachments have been found in infants of adolescent mothers. Studies also reveal th at a greater than expected incidence of intellectual delays and/or be havioral disturbances is f ound in children of adolescent mothers. Since adolescents are responsible for almost 500,000 births in the United States annually (Ventura, Martin, Curtin & Matthews, 1998) and the emphasis on health care is primary prevention, it is imperative that effec tive interventions are established to help improve the long-term outcomes of these children. Over the years, a number of infancy inte rvention programs have been developed to overcome interaction disturbances with parent training. Although many of the interventions described are dated, they demonstrate that through early intervention, mothers learn the skills necessary to provide their infants with a nurturing environment (Lambert, 1998). Badger (1980) re ported significant gains for infants and increases for the mothers in self-esteem after implementation of parent-training interventions of at risk mother-infant pairs. Similarly, Field (1980) reported encouragi ng results in her work with adolescent mothers and their preterm infants. It has also been suggested in more recen t literature (Kelly & Barnard, 2000) that the experimenter-mother interaction provi des emotional support for the mothers participating in intervention programs and that such support is an important variable enhancing the quality of maternal behavior. Further, several researchers have suggested that professionals interventi on behaviors should serve as models for parent-child interaction behaviors (Koniak-Griffin, Ver zemneiks & Cahill, 1992; Kelly & Barnard,

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17 2000.). However, there is little information on the best conditions of intervention and its effect on later development. Statement of Purpose The purpose of this study is to examine the effects of a bug-in-the-ear feedback parent training intervention on interaction behaviors between the adolescent mother and her infant. There are three specific aims fo r this study. The first is to identify and characterize the frequency of attachment be haviors exhibited in the infant/adolescent mother dyad and obtain a baseline of the frequency of the interaction on the NCAST Parent Child Interaction Scale. The second ai m is to implement an individualized bug-inthe-ear feedback parent training model to im prove the frequency and quality of infantmother interaction and assess its efficacy using the NCAST Parent Child Interaction Scale. The third aim is to compare operati onalized mother/infant attachment behavior frequencies pre and post training. Research terminology used in this study will be presented in later chapters.

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CHAPTER 2 REVIEW OF THE LITERATURE Importance of Mother Infant Interaction Guralnick & Neville (1997) summarize 20 years of prevention and early intervention research and concl ude that social competence is increasingly perceived as the central focus in the psychological development of children. The central aspect of a childs social competence and confidence is a secure attachment providing the growing child with the resilience, tr ust and ability to regulate emotions. There is compelling evidence that very early experiences are re lated to later development and antecedent studies consistently reveal that specific patt erns of interaction dur ing the first year are systematically related to a ttachment quality of the infant (Svanberg, 1998). Parental antecedents of particular interest have been the mothers sensitivity, emotional warmth and support as well as synchrony and mutua lity in the interaction (De Wolff & van IJzendoorn, 1997). Importance of interventi ons in adolescent mothers As Steele and Steele (1994) note, it is fo rtunate that a majority of mothers are secure, affectionate and consistent. However, it has also been suggest ed in the literature that adolescent mothers by virtue of their im maturity have difficulty establishing optimal interactions with their infants and this ma y compromise infant growth and development (Starn, 1992). Although research conducted on adolescent mother infant in teractions dates back to the 1980s and 1990s, the long impact continue s to resonate in public policy In 2000, 18

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19 President Clinton called on Congress to enac t his budget initiative to provide $25 million to support living arrangements for teen moth ers, help reduce repeat pregnancies and improve the help of mothers and childre n (US Department of Health and Human Services, 2000). The federal government estim ates that approximately $40 billion per year is spent on helping families that begin with a teenage birth. Studies indicate that providing early intervention programs can reduce federal spending on adolescent pregnancy sequelae (Nguyen, Parris, & Place, 2003). The Nurse Home Visitations Program in Elmira, New York, based on the Da vid Olds Home Visita tion Model has been found to be very effectiv e (Karoly et al., 1998). Review of Intervention Literature in the Adolescent /Mother Infant Dyad Over the years, a number of other infancy intervention programs have been developed in a variety of high risk populations to overcome in teraction disturbances with parent training. Because the inna te characteristics of an infa nt are difficult or impossible to alter, interventions practiced to date have focused on the behaviors of the mother or the primary caregiver. The goals of these interventi ons have been to increase competence of the parent in interpreting and respondi ng to the infants communication cues by alleviating distress and promoting growth fostering behaviors, in essence to promote synchrony (Barnett, Morisset & Spieker, 1993). In a recent study, parent-child advocate s were trained to provide one-on-one intervention facilitating healt hy parent-child interactions in a homeless population. They focused on training parents how to increas e sensitivity and responsiveness to their children. Specific, positive and individualized feedback to parents related directly to increasing the quality of the parent-child interaction (Kelly, Buehlman & Caldwell, 2000). Other researchers also have examined strategies used by effective parent trainers

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20 to produce changes in parent behaviors (Dange l & Polster, 1984). Stra tegies identified as successful include clear di rections and specific feedback with praise. Hester, Kaiser, Albert and Whiteman (1996) found that coaching, providing positive examples giving specific instructions and giving specific rather than general feedback were effective parent training strategies and conclu ded that early intervention personnel should be taught to use these stra tegies in the early intervention setting. Bernstein et al (2001) emphasized that in order to support th e parent-child relationship, an interventionist must go beyond traditional early intervention and parent education. Instead emphasis should be placed on the verbal and physical ongoing communication between each mother and their vulnerable child. In summary, it is evident from the precedi ng literature review th at effective motherinfant interaction may be compromised in th e adolescent mother/infant dyad, leading to negative outcomes in the child. It is ther efore imperative that current, effective interventions are estab lished to help improve the long-te rm outcomes of these children. A majority of the adolescent parenting programs described in the literature are group oriented and are not directed at improving the mother-infant interaction. Instead they focus on the acquisition of knowledge and skills to increase competence in caring for the infant. Further it is important to recognize that different adolescent mothers will have varied strengths and may need different kinds of help with rega rd to preventative strategies (Svanberg, 1998). A one-size fits all approach to intervention may not always apply to the individual mother/ infant dyad. These shortcomings clearly underscore the importance of using an alternative research approach in exploring effective parent

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21 training interventions. More res earch is needed on low cost training strategies that are uniquely suited for individual caregiver needs. Therefore, the proposed study will address these concerns by employing a single subjec t design and an individualized intervention with antecedent stimulus delivered to the adolescent mother via a simple wireless earphone, also referred to as bug-in-the-ear (BITE) feedback. Bug-in-the-ear feedback (BITE) Immediate feedback has been found to be mo re effective than de layed feedback in increasing desirable behaviors such as teaching, how to de liver positive consequences and instructional prompts (OReilly, Renzag lia & Lee, 1994). For example, Lancioni & Boelens (1996) demonstrated the efficacy of immediate computer delivered feedback in increasing the drawing accuracy of ch ildren with mental retardation. A number of studies have used the bug-in-the-ear feedback to deliver immediate feedback. Such studies fall into three cat egories. One area of focus is providing immediate and corrective feedback to couns eling trainees with the overall aim of improving clinical intervention skills (Gallant, Thyer & Ba iley, 1991). A second area of focus using BITE is with teachers with em phasis on skill acquisition and finally using BITE with parents who are provided immediate f eedback when dealing directly with their children, the focus on increasing desirable pa renting skills (Crimmins, Bradlyn, St. Lawrence & Kelly, 1994; Wolfe et al., 1982). Advantages of using an earphone that re ceives a transmitted signal are numerous. In addition to minimizing disruption and pr oviding immediate feedback, the use of electronic instrumentation such as the BITE de vice can be used when individuals are not trained in complex intervention techniques (Coleman, 1970). It al so eliminates the risk of observer influence when used for interv ention training. Further, with todays

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22 technological advances, this technique may fit we ll with the learning styles of todays adolescent. Accustomed to immediate grat ification, youth today are responsive. They crave stimulation and expect immediate an swers and feedback (Brown, 1997). Bug-inthe-ear technique may be a good tool fo r intervention for this generation. Single Subject Design Single subject design, derived from behavior analysis, is a research design that provides an experimental model for the study of individuals over time. The design is a clinically viable, controlled experimental appr oach to the study of a single case or several subjects, and the flexibility to observe change under ongoing treatment (Portney & Watkins, 2000). Single subject design require s the same attention to logical design and control as any other experimental desi gn based on a research hypothesis. The independent variable is the intervention a nd the dependent variab le is the subjects response defined as the target behavior that is observable, quantifiable and a valid indicator of treatment effectiveness (Portney & Watkins, 2000). Single subject design is wide ly used in behavior anal ysis research where it originated from and also in tr eatment design and intervention te sting research in an array of fields including special educ ation, social work and learning disabilities as well as in a number of allied health researches ranging from occupational therapy, physical therapy, disability rehabilita tion and medical gastroenterology (Elder, 1997; Madsen & Bytzer, 2002; Zhan & Ottenbacher, 2001;). The gold standard of nursing research thus far remains the group comparison design with a de arth of nursing research studies using single subject design. There are numerous characteristics of singl e subject design that makes it a powerful research approach, particularly when deali ng with individual subjects. Those elements

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23 that distinguish single subj ect design from group designs or case study include baseline logic; each subject serving as his own control; replication and visual analysis of the data (Bailey & Burch, 2002). This methodology is most appropriate for this research question that addresses the individuals be havior as well as the subject serving as her own control. Furthermore, by replicating the single subjec t intervention with several single subjects it may be possible to obtain a genera lized overall intervention effect.

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CHAPTER 3 METHODOLOGY Participants and Setting Three adolescent mothers and their infant s participated and completed this study. Inclusion criteria for the pa rticipants were based on condi tions that are optimal for mother/infant interactions and also based on conditions that minimi zed the risk of the impact of confounding variables such as age, racial and cultural differences on interaction behaviors. Thus, mothers recruited : (1) were close in age (2) were between the ages of 13 and 18years (3) were of similar race and socio-economic background (4) had no previous parenting experience (5) had a vagi nal delivery and (6)were in good mental and physical health as determined by their health care provider. Inclus ion criteria for the infants were(1) thirty six weeks gestation or greater (2) no congenital abnormalities (3) between the ages of zero and six months (4 ) formula fed and (5) in good general health as determined by their health care provider. Excluded from this study were mothers who were (1) older than age 18 years (2) had previous parenting experience (3) had e xperienced a cesarean section (4) in poor mental and physical health as determined by th eir health care provide r. Exclusion criteria for the infants were (1) less than thirty si x weeks gestation (2) presence of congenital abnormalities (3) greater than si x months of age. (4) currently breast feeding and (5) infants in poor health as determined by th eir healthcare provider. Formula feeding was used as an inclusion criteria to minimize the possible psychological discomfort associated with videotaping in this population, part icularly when breast feeding. Further, 24

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25 mother/infant interactions are likely to be different when formula feeding versus breastfeeding. Capital City and Gadsden County Healt hy Start Programs are community action programs that provide free comprehensive ea rly childhood health and education programs to low income children while involving their parents in the total child development process. Pregnant adolescents are an inte gral part of this program. After obtaining approval from the University of Florida In stitutional Review Boar d (IRB) and Florida Department of Health IRB, three adolescent mothers and their children and three alternates were recruited from this setti ng through a Healthy St art Social Worker. In an effort to reduce participant attriti on, the Investigator fre quently checked in by phone and maintained contact with the mothers of the participants as well as the Social Workers of the Gadsden County and Capital Area Healthy Start. Pilot Testing All procedures including instruments and the intervention were pilot tested with an 18-year old participant and her 6-month old infant who were not part of the study. The data from the pilot study provided important insight regarding how the study was to be conducted particularly in terms of the mechan ics of videotaping and the delivery of the intervention. Participant 1 Participant 1 was a pleasant, cooperativ e 15 year-old, single African American young woman who lived at home in the Tallahassee area with her mother and four teenaged siblings. She was entering the 10 th grade in an alternative school in the fall semester. This was her first pregnancy. He r pregnancy was uncomplicated and baby was vaginally delivered at term.

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26 Infant 1 This was a 3-month old African American male infant delivered vaginally at term. He weighed 6 pounds and 11 ounces at birt h He was healthy with no congenital abnormalities. He was on Carnation Good Start formula for the first three sessions and was changed to Isomil formula due to freque nt episodes of diarrhea. His weight was appropriate for his age and he had a healthy appetite. Participant 2 Participant 2 was also a 15 year-old, single African Amer ican young woman who lived at home in the Tallahass ee area with her mother and tw o teenaged siblings. She was also entering the 10 th grade in a local high school in the fall semester. This was her first pregnancy. She also had an uncomplicated pregnancy and baby was vaginally delivered at term. Infant 2 This was a 51/2-month old African American male infant delivered at term, weighing in at 6 pounds and 7 ounces. He was healthy with no congenital abnormalities. At age 51/2 months, he was rather large for his age. He ranked in the 85 th percentile for height and over the 99 th percentile for weight. He was on Isomil formula and recently had begun taking solid foods. Participant 3 Participant 3 was a 15 year-old African American young woman who lived at home with her mother and two teenag ed siblings in the Quincy/Hav ana area. This was her first pregnancy. Her pregnancy was uncomplicated except for one admission for pre-tem labor in the 7 th month. Her baby was delivered vaginally at term. She was entering the 10 th grade of an alternative high school in the fall semester.

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27 Infant 3 This was an 11/2month old African Ameri can male infant delivered at term. He weighed 7 pounds and 2 ounces at birth. He was healthy with no congenital abnormalities. His size was appropriate for his age. He was on Carnation Good Start formula and had a healthy appetite. Procedures At each mothers home, the study was thoroughly explained and informed consent obtained from the participants mothers (sin ce each participant was an adolescent and there was no parental involvement of the father s of the babies of all three participants). Assent was obtained from each of the adoles cent mothers. During the first visit, each participant was asked about general informa tion and appointments were then made for subsequent home visits wh en videotaping occurred. Experimental Procedure A non-concurrent multiple baseline design across participants was used. The demonstration of experimental control in the multiple baseline design depends upon approximately equal effects of the treatm ent being observed with each baseline. The experimenter needs to ensure that the baseli nes are as functionally equivalent as possible (Bailey & Burch, 2002). Therefore, baseline videotaping was done at the 1.00 pm feeding of the infants of all three 15 year-old mother s. After baseline st ability was reached, the intervention phase was instituted but staggered, several days to several weeks apart, across participants due to their different schedules and availability. A modified intervention (Intervention 2) was instituted for the first two participants after only subtle changes in target behaviors were observed af ter the first intervention was instituted. The third participant received the modified intervention only.

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28 There were a total of nine sessions for Part icipant 1, eight sessions for Participant 2 and six for Participant 3 (see Table 3-1). At the conclusion of the study all adolescent mothers received a gift certificate of $25-$35 (depending on the number of sessions). Table 3-1. Videotaping Schedule of Participants Baseline Sessions Interv ention 1 Intervention 2 Participant 1 X X X X X X X X Participant 2 X X X X X X X Participant 3 X X X X X Baseline Phase The Investigator videotaped each mother-infant dyad at home during numerous (three to four) 1:00 pm feeding sessions. Ba seline videotaping during feeding was done at the same time of each day for a ll participants. To minimize the risk of observer influence, the camcorder was set up on a tripod following preestablished guidelines (obtained after a pilot study) and the Investigator waited in a different room while each mother fed the baby. The baseline sessions were repeated until a stable baseline of interaction behaviors was achieved. The individualized interventi on was designed and instituted based on the occurrence or non occurrence of target behaviors that were identified during the baseline phase.

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29 Intervention To minimize observer influence and/or bi as, an instant replay camcorder set on a tripod was used during the intervention phase. This device transmitted instant images to the Investigator on a portable television set and allowed the Investigator to prompt, cue and provide reinforcement to the particip ants via a wireless headphone on desired behaviors from a different room. The first intervention involved the Investigators randomly interjecting several prompts for desi red behaviors and providing reinforcement when the desired behaviors were exhibited. Afte r several sessions with this intervention with the first two participants, very subtle ch anges in target behavi or were noticed. After debriefing with the participants, a very stru ctured modified inte rvention was developed where prompts, cues and reinforcements were given in sequence. In addition, the language used in delivering the prompts wa s simplified and specific examples of the target behavior were also give n. The instant replay was also eliminated at this time. This modified intervention incorporating participant feedback was instituted with all three participants and found to produce a significant change in target behaviors. As a result of the first two participants positive response to the modified intervention, Participant 3 received this modified intervention only af ter her baseline stability was achieved. Instruments for Evaluating Dependent Variables NCAST The Nursing Child Assessment (NCAST) Feeding scale was used to operationalize attachment behaviors as well as code att achment behaviors as they occurred in videotaped mother-infant interactions. This scale has been wi dely used in assessment of attachment behaviors and has been subjected to much validity and reliability testing. The content validity for NCAST was derived from the Bayley Test of Infant Development,

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30 the Merrill Palmer and Stanford Binet S cales and later modified according to the observations of William Fra nkenberg (NCAST, 1995). The scale demonstrates high internal consiste ncy of the total score, parent score and the infant score. The Crohnbachs alpha for th e total parent score is .87 and for the total child it is .81 (NCAST, 1995). The test-retest reli ability is better for th e parent items than for the infant items. The tota l score generalizibality coeffici ent for the parent score is 0.75 and lower for the infant, 0.53 (NCAST, 2000). The validity of the sc ale predicting later IQ has been established in several samples. A longitudinal intervention project follow up revealed that scores for fostering of cognitive growth from the 10 month feeding scale showed a correlation of ).50 with the childs Bayley Mental Developmental Index at 24 months of age (NCAST, 2000). The scale is based on the Barnard Model that assumes that mothers and infants have certain responsibilities to keep the feeding interact ion going. The infant has the role of producing clear cues and being re sponsive to the mother. The mother has the responsibility of responding to the infants cues, alleviati ng the infants distress and providing opportunities for growth and l earning (NCAST, 2000). The NCAST Feeding Scale is therefore divided into five cate gories under which ther e are a number of subcategories of attachment behaviors. In this study, due to the exhaustive na ture of the items on the original NCAST Feeding Scale, it would have been very diffi cult to code the videot aped sessions of all 76 behaviors in the subcategories. Therefore f our out of the five major categories were assessed. These important attachment behavior s were identified and operationalized using previous research in this area as well as the opinions of expert panel of pediatric health

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31 care professionals. A family care physician with a pediatric focus and three registered nurses were surveyed informally on the mo st important behaviors in the selected attachment categories. The categories were: mothers sensitivity to cues, mothers providing growth-fostering situati ons, infants clarity of cues and infants responsiveness to mother. The category of alleviation of distress was elimin ated because there was not a consistent opportunity for thos e target behaviors to be exhibited during the baseline phase of the study. Further, only 13 selected beha viors in the subcategories were measured. According to the literature, the NCAST scale has been modified and adapted for a number of reasons, including the culturally modified scale (Leon Siantz, in press). However, the rate of occurrence of attachme nt behaviors and the resulting implications have not been explored in the NCAST literatu re. In fact, the NCAST scale only measures the presence or absence of a ttachment behaviors. A number of studies have documented the internal reliability of the categories or subscales of the NCAST tool (Mogan, 1987; NcNamara, 1985). NCAST related research repo rts that the categories or subscales of sensitivity to cues, clarity of cues and res ponsiveness to parents as being the poorest in internal consistency reliability, yet there is no documentation in the literature on studies that have explored the relia bility of the individual subs cale items (NCAST, 2000). This lack of documentation on the reliability of the subscale items of this tool is a flaw of NCAST as a research tool. In this study, occu rrence rate of individua l, specific, subscale attachment behaviors was examined. Operational Definitions Independent Variables Sensitivity to cues. The three target behaviors for this category of attachment behaviors were:

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32 Mother positions the infant so that the infants head is higher than her hips. Mother comments verbally on infants hunger cues before feeding. Mother positions the child so that tru nk to trunk contact is maintained during feeding. Social-emotional growth fostering. The three target behaviors for this category of attachment behaviors were: Mother is in en face position for more than half of the feeding. Mother uses positive statements in talking to the child during the feeding Mother smiles during the feeding. Cognitive-growth fostering. The three target behavior s for this category of attachment behaviors were: Mother talks to the child using two word s at least three times during the feeding. Mother verbally describes the feeding or feeding situation to the child. Mother talks to the child about things other than the feeding. Clarity of cues. The three target behaviors for this category of attachment behaviors were: Child displays a build up of tension at the beginning of each feeding. This was further operationalized as the child shaking his head from side to side, crying and looking for the bottle at the beginning of each feeding. Child demonstrates a decrease in tension within a few minutes after feeding has begun. This was further operationalized as the child stops shaking his head from side to side and stops looking for bottle. Childs readiness for feeding. This was furt her defined as childs eagerness to feed and looking in the direction of the bottle. Th is target behavior was not included in the final analysis of the study because of the difficulty in distinguishing it from the target behavior of builds up tension. Responsiveness to Mother The two target behaviors for this category of attachment behaviors were: Child looks in the direction of the mother when feeding.

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33 Child responds to feeding. This was furt her operationalized as child relaxed with rhythmic breathing as he sucks on the bottle. Dependent VariablesFrequencies of Mother and Infant Attachment Behaviors. Different aspects of this tool have been used in similar studies where videotaped sessions were scored and coded for presence of behaviors, thus the NCAST staff were qualified in training the coders. The NCAST trainers ar e selected advanced practice nurses trained at the University of Washington where the NCAST tool was developed. In order to establish inter -observer reliabi lity, two nurse observe rs, were trained to use the NCAST tool. A third observer, who wa s not a nurse and who had not been trained in the use of the scale by the NCAST staff, was trained by a trained observer using the NCAST materials. The three independent obs ervers coded target behaviors of the videotaped sessions. The time interval coding method was used for the target behavior. Infant feeding for participants lasted be tween 6 1/2 minutes and 11 minutes. Thus, 6 minute sessions of each videotaped intera ction were coded and frequencies of occurrences of behaviors were recorded every 20 seconds. Inter-observer Reliability Inter-observer reliability checks were ra ndomly obtained for 50% of all behaviors coded and frequencies measured. The reliability checks were conducted by the three observers independently viewing the videotapes at least twice at one sitting, three days after the initial coding was completed. Inte r-observer agreement was calculated on an interval by interval basis for coding of moth er and infant behaviors by calculating the number of agreements divided by the numbe r of agreements plus the number of disagreements (Bailey & Burch, 2002). In this study, intervals in which target behaviors

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34 were not observed were counted as agreements for the behaviors that occurred in high frequency and were not counted for behaviors that occurred in low frequency. The interobserver agreement on the behavior coded was averaged to obtain the overall interobserver agreement for each attachment behavi or coded. Inter-observer reliability of 83% to 100% was obtained for the various behavi ors coded using this interval agreement calculation (see Table 3-2). The subscale item of the infants readiness to feed was eliminated from the study because of consistently poor reliability scores and the difficulty the observers had in distinguishing th at behavior from the behavior of build up in tension Data Analysis As is customary with single subject e xperimentation, the data were analyzed visually for the trends or direction of change in behaviors, which may refer to the value or magnitude of the performance at the poi nt of the intervention compared to the baseline. Since a multiple baseline design was employed in this study, data points at baseline and intervention were closely examin ed for trends, stability and variability as well as replication of the previous condition. The slope of the trend for baseline, intervention and modified intervention phases was assessed for a linear trend. Table 3-2. Inter-observer Reliability Behavior coded Participant 1 Parti cipant 2 Participant 3 Mean Reliability Head higher than hips 100% 100% 100% 100% Trunk to trunk position 100% 100% 100% 100%

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35 Comments on childs hunger 100% 100% 100% 100% Enface position 100% 100% 75% 92% Smiles during feeding 75% 87.5% 87.5% 83% Uses positive statements 87.5% 87.5% 87.5% 87.5% Talked to child using 2 + words 100% 100% 100% 100 % Describes feeding situation 100% 100% 100% 100% Talks to child about other things 87.5% 75% 87.5% 83% Response to feeding 100% 100% 100% 100% Looks in Mothers direction 87.5% 75% 87.5% 83% Builds up tension 100% 100% 100% 100% Decrease in tension 100% 100% 83% 96% ****Readiness to feed 48% 48% 48% 48% **** This attachment behavior was not incl uded in the final analysis of the study

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CHAPTER 4 RESULTS Findings Coding of six minute feeding sessions reve aled that in the baseline phase of the study, all three participants e xhibited higher frequencies of attachment behaviors that were task oriented and exhibited low freque ncies of attachment be haviors that involved communication with the infant. Attachment behaviors that were exhibited in low frequency were the target of the indivi dualized intervention. Multiple baseline design demonstrated the replication of intervention effects across participants. Experimental control was strengthened by th e display of independent base lines and the observation of change in the target behavior only when the intervention was instituted. The data for baseline and intervention phases were graphe d. Pictorial representa tion of interventions for the low frequency target behaviors demons trated that there was a cause and effect particularly between the modified in tervention and the target behaviors. Sensitivity to Cues In the baseline phase all three adolescen t mothers consistently exhibited the behaviors of positioning the infants head hi gher than hips and maintaining the trunk to trunk position the majority of the feeding time. The frequency of maintaining the position of the infants head higher than hips was almost at the ceiling acr oss all participants except during the third baseli ne session with Participant 1, when she had a lower than usual frequency of this particular target be havior as well as the be havior of maintaining the trunk to trunk position. She however went back to her baseline for both behaviors in 36

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the subsequent session. Participant 2 also ha d a consistent lower frequency compared to the other participants of maintaining trunk to trunk position in all sessions. However, she had a larger baby which may explain the lo wer frequency of this particular target behavior in this participan t (see Table 4-1 and 42). Table 4-1 Sensitivity to Cues: Frequency of Infants Head Higher than Mothers Hips Baseline Session 1 Baseline Session 2 Baseline Session 3 Baseline Session 4 Participant 1 18 17 13 17 Participant 2 18 18 18 Participant 3 18 18 18 Table 4-2 Sensitivity to Cues: Frequency of Mother Maintaining Trunk to Trunk Position Baseline Session 1 Baseline Session 2 Baseline Session 3 Baseline Session 4 Participant 1 14 14 12 14 Participant 2 9 10 10 Participant 3 16 14 16 Conversely, all three adolescent mothers rarely commented on the infants hunger during the baseline sessions, thus this behavi or was the target for intervention in this category across participants (see Figure 4-1). Participant 1 During the four baseline sessions, this pa rticipant never commented on her infants hunger cues. The first intervention resulted in a subtle change in behavior from a 37

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38 frequency of 0 during feedings to a maximu m frequency of 3 in the intervention phase. The modified intervention resulted in the highe st increase in frequency up to 5 comments made during a feeding (see Figure 4-1). Participant 2 Similarly, Participant 2 rarely commen ted on her infants cues. She made a maximum of 2 comments related to her infa nts hunger cues during the baseline phase. The first intervention yielded a maximum of 3 comments. The modified intervention resulted in this participant making 6 comme nts during a feeding related to the childs hunger (see Figure 4-1). Participant 3 Participant 3 commented only once on her infants hunger cues during two of the feeding sessions of the baseline phase. Sh e received the modified intervention only, which resulted in minimum of 4 and a maximu m of 5 comments being made related to the infants hunger at each feeding session in the intervention pha se (see Figure 4-1). Social-Emotional Growth Fostering Coding selected behaviors for the attachme nt category of social-emotional growth fostering revealed that across participants all three adolescent mothers displayed high frequencies of maintaining en face position with the infant (see Table 4-3). In contrast, there was a low incidence of the selected behaviors of smiling during feeding and using positive statements towards the infant duri ng feeding across all three participants.

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39 Table 4-3 SocialEmotional Growth Fost ering. Frequency of Mother Maintaining Enface Position Baseline Session 1 Baseline Session 2 Baseline Session 3 Baseline Session 4 Participant 1 16 18 10 18 Participant 2 16 16 15 Participant 3 18 18 15 Accordingly, the two identified behaviors of smiling during feedings and using positive statements towards the infant were the targets for intervention. Again in the fashion of multiple baseline design experimental control was determined by the independent baselines (see Figure 4-2). Participant 1 During the four sessions in the baseline phase, this participant smiled only once and never made any positive statements duri ng feeding sessions. There was a significant improvement in the frequency of the target behavior of smiling during feeding after the first intervention up to 3 smiles during a feed ing and an even higher frequency of smiling after the modified intervention up to a maxi mum of 7 times. On the other hand, there was a very subtle to no change in the behavior of using positive statements with the child after the first intervention. Both participants in the first intervention admitted to having difficulty formulating positive statements. Thus with the modified intervention, specific examples such as he is so cute and he is beautiful were given as prompts. This

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40 resulted in a slight increase in the frequency of the target behavior of using positive statements in this participant (see Figure 4-2). Participant 2 Participant 2 had a much higher frequenc y of smiling during the baseline phase. She smiled up to 4 times during a feeding session. However, she rarely used positive statements in the baseline phase. The first intervention resulted in an increase in smiling behaviors. The modified intervention resulted in an even greater increase. Consistent with the first participants pattern, the first intervention did not lead to any significant changes in the use of positive statements in this participant. The modified intervention however resulted in an increase, up to 5 comments made per feeding session in this phase (see Figure 4-2). Participant 3 This mother rarely smiled or used positive statements during the three baseline sessions. During the modified intervention phase, she smiled up to 7 times per feeding and made up to 6 positive statements about the infant per feeding session (see Figure 42).

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41 Figure 4-1.Frequency of mothers comment s on infants hunger during baseline and intervention phases 0 1 2 3 4 5 6 1 2 345678 9 Frequency of comments 0 1 2 3 4 5 6 1 2 3 4 5 6Frequency of comments Baseline 0 1 2 3 4 5 6 7 1 2 345678 Frequency of comments Sessions Structured Prompts Baseline Baseline Prompts Structured Prompts Prompts Structured prompts Participant 1 Participant 2 Participant 3

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42 Figure 4-2 Frequency of mothers smiles and use of positive statements during basee and intervention phases lin 0 1 2 Freq ue nc y of sm ile s an d + s t at eme n t s 4 5 6 7 8 9 1 2 3 4 5 6 7 8 Baselin e Prom p ts 0 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 Fr equency of sm iles and + statem ents Baselin e Prom p ts 0 1 2 3 4 5 6 7 1 2 3 4 5 6 Pro m pts Baselin e Participant 3 Fr equency of sm iles and + statem ents S t ructured prompts Partici p ant 2 S t ructured p rom p ts Partici p ant 1

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43 43 Cognitive Growth Fostering All three selected behaviors of the attachment category of cognitive growth fostering were communication behaviors. The fre quencies of the behaviors of talking to the infant using more than two words; the number of times the mother described the food or the feeding situation as well as the frequenc y of talking to the child about other things were coded in each feeding session. Interventi on was targeted for all the three selected behaviors in this attachment category. The baseline behavior s and intervention effects are illustrated in Figure 4-3. This participant talked t ds once during the first baseli bit this t nly an overall s light improvement in the frequency of ood and the feeding situation (s ee Figure 4-3). This participant reported that th la? ding Participant 1 o her infant using multiple wor ne session and three times during the thir d baseline session. She did not exhi behavior during the other two sessions in the baseline phase. Further, she never described the food nor did she talk to the infant about other things during all four baseline sessions. There was a significant improvement in the frequency of the mother using more than two words and talking to the child about other things in the fi rst intervention and ye a further increase in the frequencies of these two behaviors with the modified intervention. There was o describing the f is selected behavior was irrelevant. In her words how can you describe formu Participant 2 This participant used multiple words two times during the first baseline fee session and did not repeat this particular behavior during th e remainder of the baseline phase. She also, never described the food nor to talk to the child about other things during the baseline phase. Similar to the previous participant there was a significant

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44 improvement in the frequency of this partic ipant using more than two words an to the infant about other things in the first intervention and yet a further increase frequencies of these two behaviors with th e modified intervention. Additionally, there was only an overall slight improvement in the frequency of describing the food and the d talking in the n. Parti although f behaviors (s ee Table 4-4 and Table 4-5). Th is suggests that the infants xhibited hunger cues and were ap propriate in their res ponse to the feeding. Table Baseline Sessions Interv ention 1 Intervention 2 Infant 1 X XXXXX XXX Infant 2 X XX XX XXX Infant 3 X XX XXX feeding situatio cipant 3 The only cognitive fostering behavior exhibited by this participant in the baseline phase was using multiple words once in the first baseline session. After receiving the modified intervention, there was an increased frequency of all thr ee behaviors the behavior of describing the food increas ed in frequency minimally (see Figure 4-3). Childs Clarity of Cues All three infants consistently exhibited clear hunger cues. There was an inverse relationship between the frequency of buildi ng up tension behaviors and the frequency o decreasing tension appropriately e 4-4 Childs Clarity of Cues-Builds up Tension

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45 Table 4 Childs Clarity of Cues-Decrease in Tension BaselSessions Interv ention 1 tervent 2 ine In ion Inf ant 1 14 14 9 151515 16151 5 Infan 14 14 14 142 5 t 2 1 16 1 1 5 Infant 3 14 14 14 14141 4

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46 0 1 2 3 4 5 6 7 12456Frequency of cognitive behavior 3 0 1 2 3 4 5 6 7 8 1234578Frequency of cognitive behavior 6 0 1 2 3 4 5 6 7 8 9 10 123456789Frequency of cognitive behavior Baseline Structured p rom p ts Participant 3 Baseline Structur ed p rom p ts Prompts Figure 4-3 Frequency of moth ers exhibiting cognitive growth behaviors during baseline and intervention phases Partici p ant 2 Baseline Prom p ts Structured p rom p ts Partici p ant 3 Describes foo d Talks to child about other things Uses 2+ words Sessions

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47 Childs Response to Mother Although all three infants intermitten n of their mother in all feeding sessions in the base line phase there was an increase in the frequency of this particular target behavior w ith the communicatio at were directed at the adolescent mothers for the other attachment categories. Infant 1 This infant looked in his mothers direct ion between 6 and 10 times per feeding in the baseline phase. This behavior increased to a frequency of a maximum of 15 in the first intervention phase and a fu rther increase up to 16 in th e modified intervention phase (see Figure 4-4). tly look ed in the directio ventions th n inter Figure 4-4 Infant 1 Frequency of infant looking in mothers direction There was clearly a correlation between th e intervention effects of the mothers behavior and this particular target behavior of the infant. This was the second most pronounced increase in frequency of all the targ et behaviors measured in this particular mother/infant dyad (see Figure 4-5). 0 1 2 3 456789 2 equency of 4 16 18 Fr oection 6 8 10 12 14 looking in mms dir Mother receiving prompts Mother recei ving structured prompts Baseline Infant 1 Sessions

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48 Figure 4-5 Relationship between Inf ant 1 looking in mothers di rection and target behaviors during baseline and intervention phases 0 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 Mothers Baseline 0 2 4 6 8 10 12 14 16 4 6 7 89 1 2 3 5 0 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 89 0 1 6 9 10 1 2 3 4 5 6 7 89 2 3 4 5 7 8 Frequency of cognitive behavior Infants Baseline Infant 1 Mothers Baseline Mothers Baseline Participant 1 Par ticipant 1 Smiles and uses p ositive statements Uses cognitive growth fostering behaviors (language) Looks in mothers direction Prompts Prompts Structured prompts Frequency of looking in moms direction

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49 Infant 2 This infant also looked in his mothers direction 6 to 9 times during a feeding session in the baseline phase. This behavior increased to a maximum frequency of 15 in the first intervention phase and up to 16 in th e m 6 and Figure 4-7). This was the most pronounced change in target behaviors of this particular mother/infant dyad. Figure 4-6 Infant 2 Frequency of infant looking in mothers direction Infant 3 The behavior change in this particular in fant was more conservative. He looked in the direction of his mother 8 to 9 times pe r feeding session in th e baseline phase. This increased to a frequency of 12 and a maximu m of 14 in the modified intervention phase (see Figure 4-8). Although an improvement, the change in behavior was not as dramatic in comparison to the other two mother/infant dyads (see Figure 4-9). odified interventi on phase (see Figure 40 2 8 10 12 14 16 18Frey of lg in mo Mother receiving prompts Baseline 4 quenc 6 ookin 1 2 3456 7 8 ms direction Infant 2 Mother receiving structured prompts Sessions

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50 0 1 2 3 4 5 6 7 1 2 3 4 5 6 78Frequency of target behavior Structured prompts 0 1 2 3 4 5 6 7 8 9 12345678 0 1 2 12345678Frquenc 3 4 5ey of target or 6 7behavi 8 0 2 4 6 8 10 12 14 16 18 134 7 2 56 8 Figure 4-7. Relationship between Inf ant 2 l ooking in mothers di rection and target behaviors during baseline and intervention phases Mothers Baseline Mothers Baseline Mothers Baseline Prompts Comments on infants hun Participant 2 g e r Structured prompts Prompts Infants Baseline Infant 2 Looks in mothers direction Smiles and uses positive statements Participant 2 Participant 2 Prompts Structured prompts Uses cognitive growth fostering behavior (language)

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51 0 2 4 6 8 10 12 14 16 12345 6Frequency of looking in moms direction Mother receiving structured prompts Baseline Figure 4-8 Infant 3 Frequency of infa r nt looking in mothers direction Summary of Findings Pictorial repesentation of interven or th communication target behaviors demonstrated that there was a cause and effect particularly between the modified in ntervention consisted of structured prompting followed by reinforcem ent for each target behavior exhibited. The hange in behavior was immediate in nearly every case and the resulti ng change in infant behavior could be seen as well. The findings of the study also demonstrate the importance of communication in mother/infant interactions. ti ons f e low frequency tervention and the target behavior s. The modified i c Infant 3 Sessions

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52 0 1 2 3 4 5 6 123456Frequency of target brhavior Comments on infants hunger Participant 3 cues 0 1 2 3 4 5 6 7 8 123456Frequency of target behavior ` 0 1 3 5 123456Frequey of t 2 4ncarget beha 6 7vior Mothers Baseline 0 2 4 6 8 10 12 14 16 123456 Figure 4-9. Relationship between Infant 3 l ooking in mothers di rection and target behaviors during baseline and intervention phases Mothers Baseline Smiles and uses positive statements Partic ipant 3 Structured prompts Uses cognitive growth fostering behaviors Participant 3 Looks in Mothers direction

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53 CHAPTER 5 DISCUSSION vervie This study evaluated the effectiveness of a bug-in-the-ear feedback as an intervention to promote attachment behavior s in the adolescent mother/infant dyad. The intervention was based on an assessment of the frequency of occurrence and nonoccurrence of attachment behaviors coded and defined by the NCAST Feeding Scale. The baseline phase of the study clearly iden attachment behaviors of the verbal/comm unication type that required intervention. Additionally, after the intervention was instituted in the second phase of the study there were positivs ine mothers behaviors which in turn positively impacted infant behavior. This was particularly notable in the area of responding to the mother. Findings from this study extend and strength e earch in this area that has shown that adolescent mothers are less verbal to their in fants (BrooksGunn & Chase-Landale, 1995; Culp, Osofsky & OBrien, 1996). Additi onal studies have established the importance of in teractions between a mother a nd her infant as crucial for optim ohen, 1984; Olson, Bates & Kaskie, 1992; stimulation have been found to be more likely to have better verbal comp erleau & Malcuit 2002; Olson, Bates & Bayles, 1984). However, a number of studies have documented ggan, Devoe & B t there is a dearth of O w tified low frequency and non-occurrence of e effect th n previous res al child development (Beckwith & C Sroufe, 1985). Infants exposed to greater verbal rehension la ter o n in life (Lacroix, Pom that African American adolescents communicat e less with their infants (Barnett, Du urnell, 2002; Nitz, Ketterlinus & Brandt, 1995). Ye 53

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54 nursing research that explores the impact of this behavior on child development in African American children. Add itionally, there is a scarcity of recent intervention studies focusing on African American adolescent/infant ractions in the nursing literature. The findings of this study supp e of interventions such as parent training to improve the quality and frequency of attachment behaviors, particularly as they r ent in ss h of the e inte ort the impor tanc elate to verbal behaviors of the adolescent mother and her infant. Improvem these mother/infant behaviors ultimately can have a positive impact on the childs development. This chapter will include discussion of important similarities and differences acro adolescent mothers in this study and across study phases. In addi tion, there will be a discussion of the parent trai ning, issues of recruiting and retention, limitations of the study, recommendations for future research and implications for nursi ng practice, all wit linkages to theory. Participant Characteristics and Behaviors All three adolescent mothers were very simila r in their social characteristics. They were all African American, 15 years old, in the 10 th grade, had a varying number of teenage siblings, and lived at home with very supportive mothers who were heads household, who had themselves been teenage pare nts. None of the infants fathers were actively involved in parenting. Behaviors observed across participants during feeding sessions in the baseline pha se were very similar. Although these young women were pleasant, cooperative and quite talkative with the Investigator, they all remained very quiet when feeding their infant and appeared to approach feedi ng as a task that had to b completed. The adolescent mothers were very successful in exhibiti ng target attachment

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55 behaviors in high frequency th at were physical or task oriented including positionin infant appropriately, maintaining trunk to trunk and enface positions. Further, all participants exhibited idios yncratic behaviors during the baseline pha g the se which es to ts bottle to see how much had been consumed and how much was left. Durin In m ior with relatively little verbal in teraction has been shown in previous studies (Osof ). ne did not include any of the target att achment behaviors. These were also physical and task oriented. Although not reported in the results section of the study, these idiosyncratic behaviors were addressed with successful results during the intervention phase. Participant 1 in all sessions interrupted the feedings between two to four tim check the infan g baseline, Participant 2 prodded her infant to finish his feedings even when he was obviously satiated. Participant 3 was very interested in keeping the infants face clean her first baseline session, she interrupted the feeding to remove a tiny piece of lint fro the infants ear. During her third session, she interrupted the feeding to clean his nose. Such physical behav sky & Os ofsky, 1970; Sandler & Vietze, 1980 Communication behaviors incl uding smiling to the infant were minimal or absent across all three partic ipants. From a behaviorist sta ndpoint, Skinner (1957) explained verbal activity as an effect of environm ental contingencies, particularly audience response. Thus it can be postulated that adolescent mothers do not communicate with their infants because they do not get a response. Actually one of the participants in the study indicated that it was diffi cult to talk to an infant who did not talk back to her. Participant 2 exhibited the highest frequency of communication behaviors in the baseli phase. She smiled more and communicated more (compared to the other participants) with her 51/2-month old infant who was the ol dest infant in this group. This is probably

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56 due to the fact that this particular mother re sponded to the infants being more interactive with her because of his stage of development. This behavior is cons iste nt with research repor sed of t rcement shape the re nt n like talking on a cell about my babyits cool. ted in the NCAST literature sugges ting that behaviors including maternal vocalizations and mutual gaze increase with the age of the infant. McNamara (1985) It was evident in this study that each in fant responded to his mothers increa verbal activity by gazing in the mothers dire ction. There was an increase in frequency infants looking in their mothers direction during the intervention phases. These infants were obviously stimulated by their mothers voi ce and had their attention captured. Infan 3 had the lowest improvement in the frequency of this target behavi or of looking in the mothers direction. He was also the youngest infant (11/2 months old) in this group. Again, this finding was consistent with McNamaras (1985) research. In order to improve mother/ infant communi cation earlier on in the infants life, interventions such as those used in this study need to be instituted. Via operant conditioning, behaviorists have shown that techniques of positive reinfo pertoire of individu al behaviors (Skinner, 1957). Simple reinforcement of mother/infant communication can alter the verb al behaviors such as those observed in this study. Reinforcement was an integral f acet of the parent training in this study. Parent Training Bug-in-the-ear feedback as a vehicle for pa rent training is an innovative and curre approach to adolescent parent trainin g. All three participan ts were accepting and comfortable using the ear phone device and in trigued by the use of technology in parent training. This came as no surprise since today s adolescents are responsive and thrive o their visual and auditory senses to learn (Seel, 1997). One par ticipant stated this is just

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57 However, the first two participants targ et behavior only improved marginally in the first intervention phase. During this pha se of the study, reinforcement was randomly given to randomly interjected prompts to part icipants to exhibit target behaviors intervention format resulted in a subtle change in the frequency of the target behavior This s. Debri e articipant who was n ntrol lan initially was to recruit participants th e providers in the Tallah tional d as the referral sources. efing with the participants revealed that the participants needed more structure in their prompting, needed to be reinforced after the exhibition of each target behavior and required simplified language. This resulted in the creation of a modified intervention which was instituted in all three participan ts and was quite successful in improving the exhibition and frequency of target behaviors. This was a very interesting and importan t aspect to the study principally becaus the original intervention had been pilot te sted and was successful on a p ot part of the study. However, she wa s an18 year-old college freshman who was very different from the partic ipants of the study. This vari able was difficult to co because of the Investigators inability to c ontrol the characteristics of the participants who were recruited for the study. Recruiting for the Study Recruiting and retaining partic ipants in this study was very challenging. The p rough primary car assee/Quincy area. After a nine-month recruiting effort, no participants were interested in participating in the study. Thus Florida Department of Health Institu Review Board approval was sought to include Capital Area Healthy Start and Gadsden County Healthy Start as sites fo r recruiting. Recruiting efforts were a lot more successful at these sites. It was very important to wo rk closely with the Social Workers who were involved with the participants and w ho functione

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58 A total of 8 participant referrals were rece ived. Two potential participants decline participation after receiving information on th e study. Six participants were involved in the study at some point but 3 did not complete their participation due to an array of reasons. The participants who dropped out of the study were all between 17 and 18 years old, and most were concerned about being videotaped and paranoid about the possibility of others having access to the videotape. The ke y to retaining the par ticipants in the study was establishing a good rapport wi th the participants mothers and maintaining friendl phone contact. It was easier to establish this rapport with the mothers who were supportive of their daughters pa rticipation in d y the study. It wa s very interes ting that all three ns esented be low, including recommendations for future research. worthwhile to replicate this work with a larger sample. The three adolescent mother/i nfant dyads in this study we re all African American rch was conducted on participants from a different race and socio-cultural and culture influence adolescent moth er/infant interaction behaviors. The Investigator videotaped mother/infant interaction in the familys home during videotaping occurred, there is no information regarding what effect if any, the participants who were retained until the completion of the study had mothers who themselves were teenage mothers. The attrition rate is considered as one of the limitatio of the study. Limitations of the Study and Recommendations Several limitations of the st udy that suggest avenues for future research warrant comment. These limitations are pr Only three adolescent mother/infant dyads participated in this study. It would be and of similar socio-cultural backgrounds. It would be beneficial if future resea backgrounds. Comparisons could provide valuable information on whether race each home visit. Although the Investigator waited in another room while the Investigators presence in the home may have had on the participants behavior.

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59 However, it cannot be assumed that the intervention implemented in the mother/infant interaction behaviors. Thus, a solution would be to extend the amount of parent training that is required to maintain optimal mother/infant analysis of the study due to poor inter-observer relia bility. Another sub item infant. It is therefore imperative that fu rther research is conducted to explore the infants. Finally, it would be interesting to expl ore the reasons why some mothers were other mothers were not. This information will be invaluable in understanding the e in recruiting adolescent moth ers for future studies. Implications for Nursing Practice onstrated that a prompting intervention using a bug-in-the-ear feedback can increase the fre nt behaviors in the adolescent mother/ infant dyad which accord ing to the literature can ultimately have a positive impact on the infants development. Although the intervention was successful in this study, it is important to indicate that the bug-in-the-ear-feedback inte eh inte al mot in c well to technology, further nursing research can explore how technol ogical approaches As a result of the risk of attrition, phases of this study were not prolonged. intervention phases was comprehensive e nough to maintain longterm optimal intervention phases. Additionally, further research is needed to determine the interactions in the adol escent mother/infant dyad. One of the sub items of the NCAST Feedi ng Scale was eliminated from the final behavior emerged to be di fficult to exhibit in the mother who formula feeds her reliability of the sub items of the NCAST Feeding scale especially for formula fed interested and supportive of their daughters participat ion in the study and while social needs of the families of the adolescent mother and also could provide a guid The findings of this study dem quency of target attachme rvention was a labor intensive approach in changing mother/infant interaction baviors. Yet it can not be assumed th at the intervention implemented in the rvention phases was comprehensive enough to maintain long term optim her/infant interaction behaviors. Thus, further nursing research is warran ted on exploring the best approaches hanging these rather complex and diffi cult behaviors. Since adolescents respond

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60 sh as tele-health or computerized prompti ng can be used as a large scale inter roach to improve interaction behavior s between the adolescent mother and her nt. Nurses are at the front line and can play signif uc vention app infa icant roles in promoting nte obta bein individual family needs, set goals in collaboration with the family and modify effective inte indi reaching the desired outcome of self efficacy in the young mother. te, ent udy reported that they did not realize the importance of m im iraction behaviors in the adolescent mother/infant dyad. Good assessment or ining a baseline of behavior is an important step in the nursing process as well as g an imperative phase in effecting ch ange. Nurses must be able to identify rvention strategies such as parent training to match the identified needs of vidual mothers while maintaining the e ssential components of the intervention for The implications for nursing practice are important because the application of research to practice is significant in e xpanding the knowledge base of nursing practice related to mother/infant interactions. Unfo rtunately, there is a clear deficiency of evidence-based practice in th e context of mother/infant interactions. To illustra postpartum/newborn printed discharge instructions from eight different hospitals across the country were recently reviewed. None of these documents addressed the issue of the importance of mother/infant communication and its effects on child developm despite the empirical evidence av ailable in the nursing literature. It is also important to note that all three participants in this st other/infant communication. Hopefully, findings from this study will illuminate and make current the portance of adolescent mother/infant intera ctions, particularly as they relate to

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61 co em of young children are charged w ith identifying and implementing effective early interventio y p h te are p ed quate in ch F entions should be able to eng mmunication and infant development. In light of the current managed care era and the phasis on health promotion and disease pr evention, nurses who work with families n strategies that promote positive parentchild interactions to prevent an ossible long term cognitive sequel a in children of adolescent mothers. At present, most ospitals have a number of e ducation materials available to patients through visual chnology, computers and in print. It is imperative that nurses and other health c roviders stress the importance of optimal mother/infant interactions in their patient ucation curriculum. Additionally, since patient education alone may not be ade anging mother/infant interactions, other aven ues of intervening need to be considered. urthermore, as demonstrated in this study, the approach of the in terv age the adolescent consumer in order to ensure effective learning.

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APPENDIX INFORMED CONSENT IRB #_________ Informed Consent to Participate in Research If you are a parent as you read the information in this Consent Form, you should put yourself in your childs place to decide whether or not to allow your child to in this study. Therefore, fo r the rest of the form, the wo rd you refers to your child. take part You are being asked to take part in a re search study. This form provides you with information about the study and how your pr ivacy will be protected. The Principal Investigator (the person in charge of this re search) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Your participation is entirely voluntary. Before you decide whether or not to take part, read the information below and ask questions a bout anything you do not understand. If you choose not to participate in this study you will not be penalized or lose any benefits to which you would otherwise be entitled. 1. Name of Participant ("Study Subject") _____________________________________________________________________ 2. Title of Research Study Effect of Bug-intheEar feedback as an Intervention to Promote Attachment Behaviors in the Adolescent Mother /Infant Dyad. 62

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63 3. Principal Investigator and Telephone Number(s) Afua Ottie Arhin, MSN, RN 850-656-0358 (Home) 850-556-6613 (Mobile) Source of Fundin University of Florida Florida Nurses Foundation 5. What is the purpose of this research study? The purpose of this study is find out if a wi reless headphone can be used to help teach young mothers how to take care of their infants. 6. What will be done if you take part in this research study? In ho in e ed test ed and found to be safe and effective in milar situations. The instructions will be given by the researcher who is an experienced t by closer or change Du weeks. roximately 2 hours. Like before, you and your baby will be e 4 g or Other Material Support the first phase of the study, you will be videotaped as you feed your baby formula at me. This part of the study will last two w eeks up to a maximum of four weeks and will volve two or more home visits by th e Researcher You and your baby will be videotaped only during the home visits. Each visit will last approximately ninety (90) minutes to 2 hours. The Researcher will let you know after the first visit if this part of the study will involv more than the expected two home visits. The second part of the study is the training pha se. You will be asked to wear a wireless headphone through which you will get instructio ns on how to help your baby as you fe him/her. The instructions given will be fr om a widely used nurs ing attachment tool known as the NCAST. This tool has been si m oher/baby RN. Examples of instructions w ould be hold your ba your babys position. ring this part of the study the researcher will visit your home once a week for three Each visit will last app v idotaped. As a follow up, three weeks and four weeks after the training, you a nd your baby will be videotaped again in your home as you fee d. Each of these two visits will last approximately ninety (90) minutes.

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64 During the videotaping, the camcorder will be set up on a tripod in the room you will be feeding your baby in. The Researcher will not always be present in the room. Using the esearch assistants at a later time to m you have any questions now or at any time tact the Principal In vestigator listed in #3 of this form. have the opportunity to review the videotapes throughout the study. All videotapes will be stored in a locked cabin et in the researchers office during the time es will be destroyed. 7. If you choose to participate in this st udy, how long will you be expected to s or more. The training part will last bout three weeks and will include three sessi ons. As a follow up, three and four weeks to pa rticipate in the entire research from start finish. phone while feedi ng your infant. There are no identified risks ssociated with this study. out the study, the researchers will not ify you of new information that may you wish to discuss the information above or any discomforts you may experience, you well-known nursing tool, the videotape will be code d by r easure you and your babys interaction. If during the study, you may con You and your family will the study is being conducted. When the st udy is completed all videotap participate in the research? The first part (before you get training w ith the headphone) will last two weeks up to a maximum of four weeks and includes two sessi on a after the training you and your ba by will be videotaped again Each session will last approximately ninety minutes to 2 hours. The whole study should take no more than nine weeks, or a total of eighteen 18 hours. 8. How many people are expected to participate in this research? Six adolescent mothers and their infants will be enrolled in the research. Three adolescent mothers and their infants will be expected to 9. What are the possible discomforts and risks? You may have some minor discomfort knowi ng that you are being videotaped and having to wear a wireless head a Through become available and might affect your decision to remain in the study. If may ask questions now or call the Principal Investigator or cont act person listed on the front page of this form.

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65 10a.What are the possible benefits to you? You may or may not personally benefit from pa rticipating in this study. If the parent training interventions are shown to help how you and your baby interact, then you would directly benefit. You will also get important information that you can use in helping y our aby and how he/she grows and develops. t training has a good effect, then this method can be used to help other dolescent mothers in their inte ractions with their infants. 11. n this research study, will it cost you anything? search study? d without charge. However, hospital expenses will have to be paid by you or our insurance provider. No other compensati on is offered. Please contact the Principal vestigator listed in Item 3 of this form if you experience an injury or have any questions bout any discomforts that you experien ce while participating in this study. s want do not sign is Informed Consent Form. aw from this research study? You are free to withdraw your consent and to stop participating in this research study at b 10b. What are the possible benefits to others? If the paren a If you choose to take part i No, this study will not cost you anything. 12. Will you receive compensation for ta king part in this re You will receive $4.00 towards gift certificates to Wal-Mart for each completed session up to a maximum of nine sessions. 13. What if you are injured because of the study? If you experience an injury that is dir ectly caused by this study, only professional consultative care that you receive at the Univer sity of Florida Health Science Center will be provide y In a 14. What other options or treatments are availa ble if you do not want to be in thi study? The option to taking part in this study is not to take part in this study. If you do not to take part in this study, te ll the Principal Investigator or her assistant and th 15a. Can you withdr

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66 any time. If you do withdraw your consent, th ere will be no penalty, and you will not se any benefits you are entitled to. If you have any questions regarding your righ ts as a research subject, you may phone the Institutional Review Board (I RB) office at (352) 846-1494 or the Florida Department of stitutional Review Board at 850-245-4585 or toll free in Florida at 1-866 433-2775. 15b. If you withdraw, can information abou t you still be used and/or collected? as athered before you withdrew may be analyzed. 15cCan the Principal Investigator withdraw you from this research study? ou may be withdrawn from the study without your consent for the following reasons: re not kept on more than three occasions. If Principal Investigator feels threatened in the home environment. ity) of these records as much as the law allows. These people include the resear chers for this study, ertain University of Florida officials, the hos pital or clinic (if any) involved in this search, and the Institutional Review Board of University of Fl orida and the Florida rights and welfare of people taking part in research). Otherwise your research cords will not be released without your permission unle ss required by law or a court re published or presented at scientific meetings, your entity will not be disclosed. lo If you decide to withdraw your consent to pa rticipate in this research study for any reason, you should contact Afua O. Arhi n at (850)656-0358 or (850) 561-2874. Health, In If you withdraw no more data about you will be collected. However, information that w g Y If home visit appointments a 16. How will your privacy and the confid entiality of your research records be protected? Information collected about you and/or your baby will be stored in locked filing cabinets or in computers with security passwords. Only certain people have the legal right to review these research records, and they will protect the secrecy (confidential c re Department of Health (IRB; an IRB is a group of people who are responsible for looking after the re order. If the results of this research a id

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67 17. How will the researcher(s) benefi t from your being in this study? In general, presenting research results helps the career of a scientist. Therefore, the ic articipants will be informed in writing the findings of the study when Signatures s a representative of this study, I have expl ained to the participan t or the participant's being in the study; and how privacy will be protected. Conn res, posl my (or the participants) privacy will be protected. I ha ve received a copy of this Informed Consent Form. I will be given the opportunity to ask questions before I sign, and I have been told Principal Investigator may bene fit if the results of this study are presen ted at scientif meetings or in scientific journals. 18. Will I know the results of this study? Yes, all p completed. Again, your identity will not be disclosed A legally authorized representative the purpose, the procedures, the possible benefits, and the risks of this research st udy; the alternatives to ______________________________________________ _____________ Signature of Person Obtaining Consent Date seting Adults. I have been informed about this studys purpose, procedu sibe benefits, and risks; th e alternatives to being in the study; and how that I can ask other questions at any time. Adult Consenting for Self. By signing this form, I voluntar ily agree to participate in this study. By signing this form, I am not waiving any of my legal rights. ______________________________________________ _____________________ Signature of Adult Consenting for Self Date

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68 Parental Consent Forms for Adolescents 18 years or Les s ignatures e purpose, the procedures, the possible benefits, and e risks of this research st udy; the alternatives to being in the study; and how privacy _____ Date onsenting Adults. You (and/or the participant) have been informed about this studys d you have been told that you can ask other questions at any time. e Su y signg thisyou voluntarily ive your permission for the person named below to participate in this study. You are not er for Minor Mother) Date ______________________________________________________________________ rint: Name of Legal Representative of and Relationship to Participant: ______________________________________________________________________ S As a representative of this study, I have expl ained to the participan t or the participant's legally authorized representative th th will be protected. ______________________________________________ ________________ Signature of Person Obtaining Consent C purpose, procedures, possible benefits, and risk s; the alternatives to being in the study; and how your (or the participants) privacy wi ll be protected. You have received a copy of this Informed Consent Form. You have been given the opportunity to ask questions before you sign, an Parent/Adult Legally Representing thbject. Bin form, g waiving any legal rights for yourself or th e person you are legally representing. Aft your signature, please print your name and your relationship to the subject. ______________________________________________ _____________________ Signature of Parent/Legal Repres entative ( P ______________________________________________ _____________________ ignature of Parent/Legal Representative (for Child) Date S

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69 Adolescent Assent Form he purpose of this study is to learn the e ffects of a wireless head phone as a parent ideotaped as you feed your baby formula at home. This part of the udy will last three weeks and will involve three home visits by the Investigator. stru o how help aby as you feed im/her. This part of the study will last th ree weeks and will involve three home visits by the Investigator. Like before, you and your baby will be videotaped. lly sponsible for you gives permission, you both n eed to sign. Your signing below means at you agree to take part (a ssent). The signature of your parent/legal representative bove means he or she gives permis sion (consent) for you to take part. ____________ ignatures As a representative of this study, I have expl ained to the participan t or the participant's legally authorized representative the purpose, the procedures, the possible benefits, and the risks of this research st udy; the alternatives to being in the study; and how privacy will be protected. ______________________________________________ _____________________ Signature of Person Obtaining Consent Date T training intervention on interaction behavior s between the adolescent mother and her infant You will first be v st The second part of the study is the training pha se. You will be asked to wear a wireless headphone through which you will get inctio nsntoyour b h As a follow up, three weeks and four weeks after the training, you a nd your baby will be videotaped again in your home as you feed. Although legally you cannot "consent" to be in this study, we need to know if you want to take part. If you decide to take part in this study, and your parent or the person lega re th a Please check one of the following boxes: No, I do not want to take part in this study Yes, I want to take part in this study ________________________________________________ ______ Assent Signature of Participant Date S

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BIOGRAPHICAL SKETCH r of Science in Nursing from University of Ghana in Madi xuality and pare nting, learning styles & M Unive Afua Arhin received a Bachelo West Africa and a Master of Science in Nu rsing from University of Wisconsin in son. Her research interests are in adoles cent se and single subject methodology. She is an Assistant Professor at Florida A rsity in Tallahassee. 77