- Email: [email protected]
Feeding and attachment in infants with and without orofacial clefts
FEEDINGANDATTACHMENTIN AND WITHOUT OROFACIAL
INFANTS WITH CLEFTS
Marya C. Endriga California
State University,
Matthew
L. Speltz
University
of Washington
Catherine
Sacramento
School of Medicine
L. Mark
Karen Jones Children’s
Hospital
& Medical
Do the many feeding adversely
affect
observing
the feeding
months guishable
group
associated bond
interactions
ity of infants
with
Change
in maternal
groups,
with
with CLP were found
infants.
However,
mothers
of secure
clefts
maternal clefts,
maternal
cleft palate (CP) and cleft lip and palate
mother
and infant?
groups.
This change
3 and 12 months showing
l
INFANT
cleft lip/palate
feeding
attenuation
at 3 month
of cleft palate
the attachment related
qual-
to attachment.
of attachment
in maternal
than
to a level indistin-
to the timing
did not predict
was concurrently
by
CLP or CP) at 3 and 12
had improved
was also predictive
greater
craniofacial
anomalies
in the cleft
sensitivity
than the
& DEVELOPMENT
0 1998 ABLEX Publishing
Fax: (916) 278-6820; 21 (4), 1998, Corporation
feeding
attachment
mother-infant
interaction
Derijcke, Eerens, & Carels, 1996). A cleft is an opening in the lip or the roof of the mouth that results from arrested midline facial development during the first trimester. Initial surgi-
State University-Sacramento,
Tel: (916) 278-6735;
BEHAVIOR
during
(CLP)
was addressed
infants.
Marya C. Endriga, California
Copyright
with
was unrelated
at 3 months
at 12 months
Clefts of the lip and/or palate (CL/P) are one of the most common birth defects in the United States, occurring in approximately one of every 1000 live births (Beaty et al., 1997;
CA, 9581 g-6007.
pairs (57 infants the CLP group
feeding
sensitivity infants
This question
to be less communicative
during
between
of avoidant
isolated
by 12 months,
sensitivity
sensitivity
mothers
with
between
of 126 mother-infant
from the CP and comparison
surgery. Although
orofacial
problems
the emotional
of age. Infants
comparison
Center, Seattle
Department
of Psychology, 6000
I Street,
Sacramento,
e-mail: [email protected]. ISSN 0163-6383
pp. 699-712 All rights of reproduction
in any form reserved.
700
INFANT
cal repair of the lip generally occurs around 3 months of age and the preferred age for palate repair is approximately 12 months old (Munro, 1995). Clefts are associated with a diverse range of medical complications including feeding problems (Clarren, Anderson, & Wolf, 1987), chronic ear infections and hearing loss (Hayes, 1994), and dental and orthodontic problems (Dahllof, UssisooJoandi, & Idelberg, 1989). This paper will focus on cleft-related feeding problems and their potential effects on the mother-infant relationship. The anatomical characteristics of cleft palate (CP) greatly hinder infants’ ability to feed. Poor intraoral suction may produce choking, emission of milk through the nose, and excessive air intake. Although several specialized feeding techniques have been developed and used with reasonable success (e.g., squeeze bottles, modified bottle nipples and other feeding appliances), many infants with cleft lip and palate (CLP) or isolated CP suffer from undernourishment and compromised growth during the first year of life (Avedian & Ruberg, 1980; Jones & Orth, 1988). The feeding process can also be extremely stressful for the parents of such infants, who often struggle to find effective feeding methods. Feedings tend to be lengthy and tiring, and may last from 45 min to l/2 h (Styer & Freeh, 1981). This is well beyond the 30 min associated with “slow feeders” in normative samples (e.g., Reau, Sentura, Lebailly, & Christoffel, 1996). In order to nourish their infants adequately, parents of infants with clefts must often become highly directive and “business-like” during feedings. There is preliminary data suggesting that such problems do not have lasting effects on the physical growth of these infants beyond the infancy period (Lee, Nunn & Wright, 1996). However, the effects of these feeding problems on socioemotional growth are largely unknown. Feeding interactions are regarded as one of the most important domains of the motherinfant social relationship during the first year (Field, 1979). Not only do feedings comprise a
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Vol. 21, No. 4, 1998
large percentage of infants’ interactive opportunities in the early months of life, but the feeding situation taps many of the interactive processes critical to the formation of infant attachments to caregivers. Both the clarity of the infant’s communication of hunger, satiation, and other cues to the caregiver, and the degree of sensitivity and contingency with which the caregiver responds to these cues are expected to influence the quality of the infantcaregiver attachment relationship (Barnard, Hammond, Booth, Bee, Mitchell, & Spieker, 1989; Bowlby, 1982). Empirical support for this hypothesis has been found in studies examining the link between dyadic feeding behaviors in the early months of life and the infant’s quality of attachment at 12 months in the Ainsworth Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978). The Strange Situation is a standardized observation of separations and reunions between infants and their parents that reveals different patterns of attachment behaviors. Infants who approach the mother during reunion and show clear attenuation of separation distress upon contact with her are said to be “secure,” while those who avoid or anxiously resist contact with the mother are regarded as “insecure.” In her initial studies of this procedure with low risk infants, Ainsworth found that the mothers of securely attached 3-month old infants showed better timing of feeding initiations and terminations (relative to infants’ signals of hunger and satiation) than mothers of insecure infants. In a sample of healthy infants of socioeconomically high-risk mothers, Egeland and Farber (1984) also observed greater feeding sensitivity among the mothers of secure versus insecure infants. There is very little empirical information about the relation between infant feeding behavior and attachment. Barnard et al. found that infants’ clarity of feeding cues at 6 weeks of age was modestly and negatively correlated with ratings of attachment security, a finding that may reflect an instability in infant feeding behaviors at this early age. To our knowledge, only one study has examined the social and emotional aspects of
Feeding and Attachment
feeding interactions involving infants with orofacial clefts. Speltz, Goodell, Endriga, and Clarren (1994) observed 3 month-old infants with and without unrepaired clefts of the lip and/or palate during a feeding session with their mothers. Feeding interactions were coded with the Nursing Child Assessment of Feeding Scale (NCAFS; Barnard et al., 1989), in which trained observers recorded the presence or absence of specific infant and mother feeding behaviors. Results indicated that infants with clefts were less clear in their social cues than infants without clefts (due primarily to less smiling and less clear initiation/ satiation cues), and mothers in the CLP group showed fewer sensitive responses to their infant’s cues than mothers in the CP and comparison groups. The long-term implications of these findings for the quality of the motherinfant relationship could not be ascertained in this cross-sectional study. It might be anticipated, however, that the feeding interactions of mothers and infants with CL/P would be influenced by the surgical correction of the cleft lip or cleft palate. The current study extends the work of Speltz et al. (1994) by conducting a follow-up assessment at age 12 months of the 41 infants in that sample, plus an additional 85 subjects who were subsequently enrolled in an ongoing longitudinal investigation (total N = 126). Change in the feeding interactions of dyads containing infants with and without clefts of the lip and/or palate was examined over a 9-month period (ages 3 to 12 months). We also examined the relation between feeding interaction and quality of attachment at 12 months in both groups. Attachment quality as observed in the Strange Situation is arguably one of the best single indicators of social-emotional development in early childhood, at least in high risk samples when caregiving environments are relatively stable (Greenberg, in press); thus, attachment classification was our first-year outcome measure of psychological growth. Two specific aspects of feeding interaction were examined-infant feeding cues and maternal sensitivity-because of their the-
701
oretical relevance to the formation of attachment. Behaviors conceptually related to these constructs are targeted by two NCAFS subscales, Clarity of Cues and Sensitivity to Cues, respectively. These subscales were the focus of our analyses. The following questions and hypotheses were addressed: Is there change in the quality of motherinfant feeding behaviors during the Jirst year of life? Does change vary with diagnosis (clef vs. non-clefr)? Is change affected by “early” or “late” clefr palate surgery? Between 3 and 12 months of age, we anticipated greater positive change in the cleft group than in the noncleft comparison group (i.e., a diagnosis by time interaction), due to the significant changes in medical status experienced by infants with clefts during the first year. These include repair of the cleft lip in all of the infants with CLP during this time period, and for some infants with clefts, repair of the cleft palate as well (about 40% in our cleft sample). Although these surgical procedures are known to produce feeding complications in the immediate post-surgery period (Berkowitz, 1994), they eventually reduce oral-motor dysfunction. For infants with CLP, surgery may improve facial expressiveness (e.g., a more typical smile or grimace), therefore increasing the clarity of feeding cues. Coupled with mothers’ increasing mastery of cleft feeding techniques, these infant factors should promote greater maternal sensitivity during feeding at 12 months than 3 months. Another question was whether the occurrence or nonoccurrence of cleft palate surgery prior to 12 months was related to improved feeding interactions. We hypothesized that infants having “early” cleft palate repair (i.e., prior to 12 months) would have better infant and mother NCAFS scores than those having later repair. Is feeding interaction related to the quality (type) of attachment to mother? Ainsworth et al. (1978), in their home observations of nonimpaired infants at 3 months of age, found that the mothers of avoidant infants showed less “synchronous” interactions with their infants than mothers of secure infants, and less func-
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INFANT
tional handling and responsiveness to crying than mothers of both secure and resistant infants. We therefore hypothesized that the mothers of infants with avoidant attachment patterns-both cleft and non-cleft-would show the fewest sensitive behaviors among the three major attachment groups (secure, avoidant, and resistant). No hypothesis was tendered about the relation between infant clarity of cues and attachment, as infant characteristics in normative samples are not expected to influence attachment directly, but rather to do so indirectly by facilitating or hindering mothers’ efforts to provide sensitive care (Speltz, Endriga, Fisher, & Mason, 1997). On the other hand, the extraordinary limitations imposed by orofacial clefts on infant feeding behavior might enhance the direct effects of infant characteristics on attachment quality. Does maternal sensitivity during feeding predict attachment among infants with clefts, after controlling for cleft diagnosis? In a previous study involving the current sample of infants with clefts, infants with CP were found to be at greater risk of insecure attachment than infants with CLP (Speltz, Endriga, Maris, & Jones, personal communication, 1997). If, as hypothesized above, maternal sensitivity during feeding is also predictive of attachment, it is important to determine whether maternal feeding behaviors offer predictive value after considering the infant’s cleft diagnosis. Finally, this study also sought to obtain important descriptive information about length and methods of feeding for cleft group infants relative to the comparison group infants, and the relation of these variables to both feeding interaction and attachment.
METHOD
The participants were 126 infants and their mothers. Twenty-nine of the infants had CLP
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Vol. 21, No. 4, 1998
and 28 infants had CP. Infants in the cleft groups were consecutive, eligible referrals to a craniofacial program at a children’s hospital in a metropolitan area. Infants with more extensive birth defects were excluded, as were infants with other complicating prenatal or peri-natal factors (i.e., prematurity, twinning, maternal chemical dependency, post-natal trauma). The non-impaired comparison group (COMP) consisted of 69 healthy, typically developing infants and their mothers. COMP group infants were recruited through pediatric clinics and community centers and were enrolled in the study if they matched infants with clefts with respect to age, gender, ethnicity, maternal age, socioeconomic status, parity, and parent marital status. The first visit (“Time 1”) occurred prior to the CLP infants’ initial lip repair, at approximately 3 months of age (M = 2.9 months, SD = 0.6). The average maternal age at Time 1 was 27 years (SD = 6). One hundred-seven (85%) of the infants were Caucasian, 6 (5%) were African-American, 4 (3%) were Asian, 1 (1%) was Hispanic, and 8 (6%) had multi-ethnic backgrounds. Approximately half of the infants were female (49%). Forty-two percent of the mothers were primiparas. Eighty-three percent of the households had two parents. Families were of middle socioeconomic status (M = 3.1, SD = 1.2) as measured by the Hollingshead 4-factor Index (Hollingshead, 1975).’ No si gniticant group differences between the comparison and combined cleft groups were found on any background variable. There were significantly more females in the CP group (75%) than in the CLP group (31%),x2(1)= ll.l,p<.OOl,whichisconsistent with population gender differences for these disorders. The follow-up assessment (“Time 2”) was conducted, in most cases, within 2 weeks of the infant’s first birthday (M = 12.3 months, SD = 0.6). One hundred-sixteen dyads participated at Time 2. Ten dyads failed the followup assessment (2 CLP, 4 CP, 4 COMP). Reasons for this attrition included moving, inability to contact the family, and dissatisfaction
Feeding and Attachment
with the study. The 10 failed cases were found to have lower SES, F(1, 114) = 5.8, p c .05, and younger maternal ages, F( 1, 114) = 7.8, p < .Ol than the remaining sample. Within the remaining sample, there were no differences between the combined cleft group and the comparison group on child age, child ethnicity, child gender, maternal age, parity, SES, or marital status. As at Time 1, child gender was the only background variable that differed between the two cleft groups. Again, there were significantly more females in the CP group than in the CLP group x2( 1) = 10.47, p c .OOl). Four additional subjects were lost for some analyses because of videotape failure (1 CLP dyad), incomplete feeding sample (1 COMP dyad, 1 CLP dyad), and unclassifiable attachment (1 CLP dyad with developmental delay).
Measures Assessment
of Feeding
The quality of mother-infant interaction during feeding was measured with the NCAFS. The NCAFS contains 76 dichotomous items in which the presence or absence of a desired parent or infant feeding behavior is indicated by a trained coder. The items are grouped in relation to four subscales pertaining to the parent (sensitivity to cues, response to distress, social-emotional growth fostering, and cognitive growth fostering), and two subscales related to the infant (responsivity to parent, clarity of cues). Subscale and total scores reflect the sum of items in which a desired feeding behavior was observed to occur. Validity and reliability data are reported in Barnard et al. (1989), with Cronbach’s alphas of .73 for infant total scores, .83 for parent total scores, and alphas for specific subscales ranging from .56 to .69. In this study, two subscales were selected for analysis: infant Clarity of Cues and maternal Sensitivity to Cues. These subscales were chosen because they are the most relevant to the theoretical and empirical asso-
703
ciations between feeding and attachment described earlier, and they were shown by Speltz et al. (1994) to discriminate one or both cleft groups from the comparison group. The Clarity of Cues scale contains items such as “child signals readiness to eat” and “child smiles or laughs during feeding.” Examples of Sensitivity to Cues items include “parent comments verbally on child’s hunger cues prior to feeding” and “parent does not offer food when child looks away.” Alphas obtained from the current data set for Clarity of Cues and Sensitivity to Cues were, respectively, .65 and .59 for Time 1, and .54 and .40 for Time 2. All coders were trained through the Nursing Child Assessment Satellite Training program (NCAST) at the University of Washington (Seattle, WA). The same NCASTtrained coder coded the majority of interactions at Time 1 and Time 2. Two coders served as secondary or reliability coders. Interrater reliability was established for each NCAFS item for 33% of the sample. At Time 1, mean percent agreement across all items was 91.2% (mean kappa = .65) and at Time 2, mean percent agreement was 90.6% (mean kappa = .60).
Measurement
of Attachment
at Time 2
Videotapes of the Strange Situation (SS; Ainsworth & Wittig, 1969) were observed by two graduate student coders supervised by Robert Marvin at the University of Virginia. Coders were blind to all aspects of the study. Although in the CLP group some scarring and nasal distortion were potentially visible, postcoding interviews with the coders indicated that facial impairments were unnoticed in all but a few infants; the coders reported being unaware of the specific groups under study. Infant behavioral patterns in the SS were classified into four groups: Avoidant (A), Secure (B), Resistant (C), and Disorganized (D), as described in Ainsworth et al. (1978) and Main and Solomon (1990). However, only one cleft group infant received a D classification, so this child was “force classified” into its 3-way cat-
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egory (B) for the purposes of this study. All coder disagreements and all infants receiving D classifications by either coder were conferenced with R. Marvin. All participants were coded by both coders. There was 83% agreement and a Cohen’s kappa of 60 for the 3group classification. For dichotomous classification (secure, insecure), there was 82% agreement and a kappa of 55. In the same sample of infants described here, Speltz et al. (1997) found that diagnostic groups (cleft versus comparison group infants) did not differ significantly in their 12-month attachment status.
Procedure
Time 7 Assessments were scheduled to coincide with each infant’s typical period of alertness and hunger. After signing a consent form approved by the hospital’s Institutional Review Board, mothers participated in a semistructured interview with the experimenter followed by brief unstructured mother-infant play tasks and a standardized infant development assessment (not reported here). Infants were fed when hungry. The room was equipped with a cushioned rocker and straight-backed chairs, magazines, and a screened-off video camera. An observation room with a mirrored window was situated approximately 10 feet from the chairs and contained a second video camera and a female videotaper. Mothers were shown the observation room and introduced to all research staff prior to the assessment. Towards the end of the visit, the infant’s photograph was taken and mothers filled out a questionnaire packet while their infants slept or were cared for by research staff.
Time 2 Following a second interview to update medical and family information, mothers and
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Vol. 21, No. 4,1998
infants participated in the Strange Situation. Then, the mothers and infants participated in feeding and play interactions and infants were given a developmental exam and photographed. Afterwards, the mothers completed the questionnaire measures.
RESULTS
Length and Method
of Feedings
Time 1 Complete feeding observations were obtained for 125 dyads at Time 1 (1 COMP subject did not complete the feeding task). The mean feeding length at Time 1 was 18 min (SD = 9.3, range = 4-55 min). Group differences were found in length of feeding, F (2, 123) = 3.2, p c .05. Feedings in the CLP (M = 19.9, SD = 10.9) and CP (M = 20.7, SD = 12.7) groups were longer than in the comparison group (M = 16.4, SD = 6.3). Length of feeding was uncorrelated with NCAFS maternal sensitivity at Time 1. However, there was a significant correlation between Time 1 infant clarity of cues and length of feeding (r = .18, p < .05), indicating that infants with more frequent indicators of clear feeding cues had longer feeding sessions. Follow-up analyses indicated that this relationship was only significant within the CLP group (r = .42, p < .05). Group differences were also present in the method of feeding at Time 1. Only 3 (5.4%) infants in the combined cleft groups were breast-fed compared with 39 (57.4%) breastfed comparison group infants; 53 (94.6%) cleft group infants were bottle-fed, compared with 29 (42.6%) bottle-fed comparison infants, x2 = (1) = 37.07, p c .OOl. One infant with CLP was gavage (“tube”) fed. As method of feeding was confounded with diagnosis (cleft versus comparison group status) and there were very few breast-fed infants with clefts, relations between feeding method and other variables were examined only within the comparison group. T-tests comparing the
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COMP infants demonstrating clearer cues than CLP infants [t(42) = -2.68, Bonferroni correctedp < .0167]. No significant diagnostic group differences were detected at Time 2. T-tests were used to compare the Time 2 feeding interactions of cleft group infants receiving cleft palate surgery either before (n = 20, 40%) or after (n = 30, 60%) the Time 2 assessment. No significant differences in infant clarity of cues or maternal sensitivity were found. Relations between Attachment Cleft Group
Feeding and
infants
Infants with CLP and CP were combined to form a single cleft group for these analyses, due to insufficient cell sizes when cross-tabulating the 3 attachment categories (secure, avoidant and resistant) and both cleft diagnoses. Table 2 summarizes the descriptive statistics for feeding interaction scores by attachment classification for the cleft group. Within the cleft sample, results of a repeated measures analysis of vari-
14
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ante for maternal sensitivity by attachment classification revealed a significant interaction of attachment by time [F (2,45) = 3.38, p < .05] and a significant main effect of time [F (1,45) = 2 1.94, p c .OOl]; maternal sensitivity decreased over time. Follow-up analyses of the simple effects of attachment classification at each time point revealed that maternal sensitivity at Time 1 was unrelated to 12-month attachment classification. At Time 2, there was a significant effect of attachment on maternal sensitivity scores, F (2,47) = 4.42, p < .05. Post-hoc comparisons indicated that avoidant infants had significantly lower maternal sensitivity scores than secure infants [t(37) = -3.29, Bonferroni corrected p < .0167]. Follow-up simple effects analyses of time for each attachment classification indicated that maternal sensitivity decreased over time significantly for avoidant [F(1,45)=12.51,p<.OOl]andresistant[F(l, 45) = 5.91, p < .05] infants. This finding is shown in Figure 2. Results of a repeated measures analysis of variance for infant clarity of cues found a significant main effect of time [F (1,45) = 40.34, p < .OOl], with clarity increasing over time.
1
10 Time 2
Time 1 FIGURE 1 NCAFS
clarity of cues scores over time by diagnostic group (full sample).
Feeding
707
and Attachment
ment (1) = 4.9, p c .05, R = -.20). Diagnosis and change in maternal sensitivity each resulted in the same overall level of correct case classification (69%). Knowing both diagnosis and change in maternal sensitivity improved prediction to 77% overall (90.1% for secure cases, 46.7% correct for insecure cases). The odds ratios in this regression model indicated that insecure attachment was 4.4 times more likely than secure attachment for infants with cleft palate, and .71 more likely with each unit of negative change in maternal sensitivity.
No significant main effect of attachment or time by attachment interaction was detected. In order to determine the relative power of cleft diagnosis and maternal sensitivity change scores to predict attachment, a logistic regression was conducted using two-way attachment classification (secure versus insecure) as the dependent variable. Covariates were entered hierarchically with cleft diagnosis first and change in maternal sensitivity second in the initial analysis; the process was then reversed in order to determine which variable accounted for the greatest variance. Both diagnosis and change in maternal sensitivity accounted for significant variance in the logistic regression equation, whether entered first or second, indicating that each contributed independently to the prediction of attachment status. When cleft diagnosis alone was entered in the logistic regression equation, it predicted attachment status [model x2 (1) = 5.3, p c .05, R = .21. When entered second, after the maternal sensitivity change score, diagnosis significantly improved the model (improvement x2 (1) = 4.6, p < .05, R = .20). When only change in maternal sensitivity was entered into the regression equation, it also predicted attachment status [model x2 (1) = 5.2, p < .05, R = -.21]. When entered second, after diagnosis, change in maternal sensitivity significantly improved the model x2 improve-
Comparison
Group
Infants
Table 3 summarizes the descriptive statistics for feeding interaction scores by attachment classification for the comparison group. No significant main effects of attachment classification or attachment by feeding interactions were detected for maternal sensitivity or infant clarity of cues.
DISCUSSION The results of the current study differ from Speltz et al.‘s (1994) findings, in that fewer differences in feeding interactions were revealed between the cleft and comparison groups in the
TABLE 2 Attachment
classifications
and NCAFS subscale Time
M
scores within
the Cleft Group
1
Time 2
SD
M
SD
Maternal Sensitivity A (n = 6)
13.50
1.38
10.33
1.51
6 (n = 33)
13.00
1.95
12.24
1.28
C (n = 9)
13.67
2.06
11.89
1.97
0.63
Infant Clarity of Cues
Note
A =
A (n = 6)
8.83
3.25
14.00
B (n = 33)
10.73
2.56
13.39
1.44
c (n = 9)
10.78
1.64
13.56
2.01
avoidant, B = secure, C = ambivalent/resistant
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Time 2
Time1 FIGURE 2
NCAFS
sensitivity
scores over time by attachment classification
present sample. Speltz et al.‘s (1994) results were based on a smaller sample containing the fust 41 subjects enrolled in the current sample of 126, assessed only at Time 1. The present findings are based on a larger sample of families, participating in both the Time 1 and Time 2 assessments, who had higher SES and older maternal age than those not attending the Time 2 assessment. In the Barnard et al. (1989) standardization sample, mothers with more education (which, along with occupation, comprises SES) were found to have higher NCAPS scores. The Barnard study did not examine maternal age, but it might be anticipated that older mothers would be more skilled at feeding their infants due to greater maturity or more experience with infants. The NCAPS Clarity of Cues scale contains items referring to infants’ hunger and satiation cues, alertness and activity level, and various social behaviors such as eye contact, vocalization and smiling directed at the mother. In the current study, the CLP group showed signifi-
(clefts only).
cantly fewer of these behaviors during feeding at age 3 months than comparison group infants. This finding is consistent with previous reports of greater passivity and less facial expressiveness among infants with clefts than those without clefts (Starr, Chinsky, Canter, & Meier, 1977). However, at 12 months, the cleft and comparison groups were indistinguishable, indicating that the infants with CLP had “caught up” in this communicative aspect of feeding. Unfortunately, our data do not provide a ready explanation for this improvement among the CLP group infants. It cannot be attributed to either cleft lip or cleft palate surgery, as both cleft groups showed equivalent positive change (thus eliminating cleft lip surgery as uniquely contributory) and clarity of cue scores did not vary by date of cleft palate surgery (before or after the 12 month feeding assessment). At this point we can only speculate that either familiarity with mothers’ feeding style or an attenuation of risk factors common to both cleft groups-such as poor
Feeding and Attachment
709
TABLE 3 Attachment
classifications
and NCAFS subscale scores within the comparison Time 1 M
group Time 2
SD
M
SD
Maternal Sensitivity A (n = 12)
13.75
1.60
11.83
1.90
B (n = 46)
14.04
1.30
12.35
1.75
C (n = 6)
14.33
1.63
12.50
1.98
Infant Clarity of Cues A(n=
Note
12)
10.92
1.62
13.17
1.47
B (n = 46)
12.02
2.08
13.57
1.34
C (n = 6)
12.00
1.41
14.17
.9a
A = avoidant, B = secure, C = ambivalentkristant
weight gain or elevated risk of illness-contributes to these infants’ improving feeding communications over time. Observed maternal sensitivity during feeding at 3 months did not predict attachment within the cleft group. However, a concurrent relation was found between attachment and maternal sensitivity at 12 months, and change in maternal sensitivity between 3 and 12 months was predictive. As hypothesized, the mothers of insecure-avoidant infants showed fewer sensitive behaviors than mothers of secure infants, and greater negative change in maternal sensitivity than mothers of secure infants. The mothers of avoidant infants with clefts showed a more pronounced manifestation of the trend found in all groups for declining sensitivity scores over time. Conversely, the mothers of secure infants with clefts were more likely to show behaviors that opposed this trend. Thus, while 84% of mothers in the avoidant group showed negative change in sensitivity, only 50% of mothers in the secure group did so. The logistic regression analysis indicated that change in maternal sensitivity was as important as cleft diagnosis (CLP or CP) in predicting the dichotomous attachment status of infants with clefts (secure or insecure). Both variables contributed independently to the prediction of attachment and
together they provided a better prediction of attachment status than either alone. Infants’ clarity of cues was not predictive of attachment at either time point. It is possible that the significant improvement in clarity of cues shown by cleft group infants was associated with mothers’ change in maternal sensitivity. However, in a post hoc analysis that addressed this question, we found no association between change in clarity of cues scores and change in maternal sensitivity (r = .005). Thus, there is no evidence that change in infant feeding behaviors affected attachment indirectly by way of maternal sensitivity. What other factors might account for change in maternal sensitivity, if not infant feeding behavior? Cleft surgeries were not explanatory, as both cleft groups showed equivalent declines in maternal sensitivity, and maternal sensitivity scores were unrelated to cleft palate surgery date. As decline in sensitivity was most pronounced in the insecureavoidant group, we considered the maternal characteristics that have been associated with avoidant infants in other samples. One prominent factor is maternal mood (depressed and/ or anxious), which has been shown to distinguish the mothers of secure and avoidant infants in high social risk samples (e.g., Lyons-Ruth, Botein, & Grunebaum, 1984;
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INFANT
Stevenson-Hinde & Shouldice, 1995). Another factor is maternal personality style. There is some evidence that mothers of avoidant infants are more likely than other mothers to adopt a defensive posture in their reports of self and family emotions and conflict; in other words, they attempt to minimize or avoid negative emotions (Spieker & Booth, 1988). In order to explore these possibilities, a post hoc analysis was undertaken in which the association between change in sensitivity and mothers’ self-reports of parenting-related stress and negative mood was examined in the cleft group (using the Parenting Stress Index parent score; see Abidin, 1990). Significant relations were found between change in sensitivity during feeding and parenting stress at 3 months (I = .44, p < .Ol) and 12 months (r = .30, p < .04), indicating that higher stress scores were associated with more positive change in sensitivity during feeding among the mothers of infants with clefts. In the comparison group, there were no significant relations between parenting stress and maternal sensitivity. This post hoc finding suggests a hypothesis for further investigation: Among the mothers of infants with CL/P, change in maternal sensitivity during feeding is related to selfreports of stress and negative mood states, with positive change more likely for those mothers who openly acknowledge the stress associated with caring for an infant with this type of congenital defect. This study has several limitations that render some findings tentative. Small sample size, which is an everpresent problem in the study of rare medical disorders, prevented the analysis of attachment classification by specific cleft diagnosis. The effects of small sample size were only partially offset by combining the cleft groups together for the attachment analyses. There were still very small numbers of infants with insecure-avoidant and insecure-resistant attachments (n’s of 6 and 9, respectively). We can place the most confidence in analyses that used the dichotomous categorization of attachment (secure versus insecure). Another problem is the low internal consistency of the
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NCAFS subscales selected for analysis, particularly the maternal sensitivity subscale at 12 months (a = .40). In Barnard’s et al. (1989) standardization sample, the feeding subscale alphas were also relatively low and these authors recommended use of the parent and child total scores, at least for clinical purposes. However, we elected to prioritize the specific theoretical match between the scales that were used and attachment theory. The total parent and child scales were felt to be too broad for our purposes. In future studies with larger samples of infants with clefts, factor analysis of the NCAFS may be necessary to derive statistically sound scales for use in this population. It is also important to note that the findings regarding maternal sensitivity and avoidant attachment are essentially concurrent and therefore the direction of effect between these two variables is uncertain. Decline in maternal sensitivity could have promoted avoidant attachment or vice-versa. Nevertheless, our findings suggest that there is potential utility in the clinical observation of mother-infant feedings in the cleft population, particularly if methods like the NCAFS are used to detect changes in maternal sensitivity over the latter half of the first year. Further research to replicate these findings is needed before clinical applications of these findings are considered. It is also important to demonstrate that the outcome measure used herein-attachment status at 12 months-is indeed predictive of subsequent psychological outcomes in the cleft population. Work is underway in our longitudinal project to test this hypothesis with the current sample of children at school entry. Acknowledgments: This research was supported by NICHHD grant ROl-HD25987-08. We would like to thank Kris Barnes, Lynne Foss, and Jacquie Stock for their coding of the NCAFS data; Robert Marvin, Maria Morog, Tom O’Connor for their coding of attachment data; and Sterling Clarren and Wendy Mouradian for the referral of patients to this research
feeding and Attachment
project. We would also like to thank the families who have participated in this research.
NOTES 1. Updated additions to Hollingshead’s categories were provided by T. M. Achenbach (personal communication, 1997).
REFERENCES Abidin, R. R. (1990). Parenting stress index (3rd ed.). Charlottesville, VA: Pediatric Psychology Press. Ainsworth, M D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment. Hillsdale, NJ: Erlbaum. Ainsworth, M. D. S., & Wittig, B. (1969). Attachment and exploratory behavior of one-year-olds in a Strange Situation. In B. M. Foss (Ed.), Determinants of infant behavior (vol. 4, pp. 111-136). London: Methuen. Avedin, L., & Ruberg, R. L. (1980). Impaired weight gain in cleft palate infants. Cleft Palate Journal, 17,24-26.
Barnard, K. E., Hammond, M. A., Booth, C. L., Bee, H. L., Mitchell, S. K., & Spieker, S. J. (1989). Measurement and meaning of parentchild interaction. In E Morrison, C. Lord, & D. Keating (Eds.), Applied developmental psychology (vol. 3, pp. 39-79). San Diego: Academic Press. Beaty, T. H., Maestri, N. E., Hetmanski, J. B., Wyszynski, D. F., Vanderkolk, C. A., Simpson, J. C., McIntosh, I., Smith, E. A., Zeiger, J. S., Raymond, G. V., Panny, S. R., Tifft, C. J., Lewanda, A. F., Cristion, C. A., & Wulfsberg, E. A. (1997). Testing for interaction between maternal smoking and TGFA genotype among oral cleft cases born in Maryland 1992-1996. The Cleft Palate-Craniofacial Journal, 34(5), 447-454.
Berkowitz, S. (1994). The clef palate story. Chicago: Quintessence Books. Bowlby, J. (1982). Attachment and loss: Volume 1. Attachment (2nd ed.). New York: Basic. Clarren, S. K., Anderson, B., & Wolf, L. S. (1987). Feeding infants with cleft lip, cleft palate, or cleft lip and palate. Cleft Palate Journal, 24, 244-249.
711
Dahllof, G., Ussisoo-Joandi, R., & Idelberg, M. (1989). Caries, gingivitis, and dental abnormalities in preschool children with cleft lip and/or palate. Cleft Palate Journal, 26,233-237. Derijcke, A., Eerens, A., & Carels, C. (1996). The incidence of oral clefts: A review. British Journal of Oral and Maxillofacial Surgery, 34(6), 488-494. Egeland, B., & Farber, E. (1984). Infant-mother attachment: Factors related to its development and changes over time. Child Development, 55, 753-771.
Field, T. M. (1979). Interaction patterns of pre-term and term infants. In T. M. Field (Ed.), btfants born at risk: Behavior and development (pp. 333-356). Jamaica, N.Y.: Spectrum Publications. Greenberg, M. T. (in press). Attachment and psychopathology in childhood. In J. Cassidy & P R. Shaver (Eds.), Handbook of attachment theory and reseamh. NY Guilford. Hayes, D. (1994). Hearing loss in infants with craniofacial anomalies. Otolaryngology Head Neck Surgery, HO, 39-45.
Hollingshead, A. B. (1975). Four factor index of social status. New Haven, CT: Yale University. Jones, W. B(1988). Weight gain and feeding in the neonate with cleft: A three-center study. Clef? Palate Journal, 25(4), 379-384.
Lee, J., Nunn, J., & Wright, C. (1996). Height and weight achievement in cleft lip and palate, Archives of Disease in Childhood, 76,70-72.
Lyons-Ruth, K., Botein, S., & Grunebaum, H. V (1984). Reaching the hard-to-reach: Serving isolated and depressed mothers with infants in the community. New Directions for Mental Health Services, 24,95-122.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 121-160). Chicago, IL: University of Chicago Press. Mumo, I. R. (1995). A description of craniofacial anomalies: The mechanism and rationale of surgery. In R. A. Eder (Ed.), Craniofacial arzomalies: Psychological perspectives (pp. 3-2 1). NY Springer-Verlag. Reau, N. R., Sentura, Y. D., Lebailly, S. A., & Christoffel, K. K. (1996). Infant and toddler feeding patterns and problems: Normative data
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and a new direction. Journal of Developmental and Behavioral Pediatrics, 17(3), 149-153. Speltz, M. L., Endriga, M. C., Fisher, F? A., & Mason, C. A. (1997). Early predictors of attachment in infants with cleft lip and/or palate. Child Development, 68, 12-25. Speltz, M. L., Goodell, E. W., Endriga, M. C., & Clarren, S. K. (1994). Feeding interactions of infants with unrepaired cleft lip and/or palate. Infant Behavior and Development, 17(2), 13 l140. Spieker, S., & Booth, K. (1988). Maternal antecedents of attachment quality. In J. Belsky & T. M. Nezworski (Eds.). Clinical implications of attachment (pp. 95-135). Hillsdale, NJ: L. Erlbaum & Associates.
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Starr, I’., Chinsky, R., Canter, H., & Meier, J. (1977). Mental, motor, and social behavior of infants with cleft lip and/or palate. Clef Palate Journal, 14, 140-147. Stevenson-Hinde, J., & Shouldice, A. (1995). Maternal interactions and self-reports related to attachment classifications at 4.5 years. Child Development, 66, 583-596. Styer, B. S. & Freeh K. (1981). Feeding infants with cleft lip and/or palate. Journal of Obstetrics, Gynecology, and Neonatal Nursing, 10, 329-332.
30 December
1997;Revised 08 May 1998n
INFANTS WITH CLEFTS
Marya C. Endriga California
State University,
Matthew
L. Speltz
University
of Washington
Catherine
Sacramento
School of Medicine
L. Mark
Karen Jones Children’s
Hospital
& Medical
Do the many feeding adversely
affect
observing
the feeding
months guishable
group
associated bond
interactions
ity of infants
with
Change
in maternal
groups,
with
with CLP were found
infants.
However,
mothers
of secure
clefts
maternal clefts,
maternal
cleft palate (CP) and cleft lip and palate
mother
and infant?
groups.
This change
3 and 12 months showing
l
INFANT
cleft lip/palate
feeding
attenuation
at 3 month
of cleft palate
the attachment related
qual-
to attachment.
of attachment
in maternal
than
to a level indistin-
to the timing
did not predict
was concurrently
by
CLP or CP) at 3 and 12
had improved
was also predictive
greater
craniofacial
anomalies
in the cleft
sensitivity
than the
& DEVELOPMENT
0 1998 ABLEX Publishing
Fax: (916) 278-6820; 21 (4), 1998, Corporation
feeding
attachment
mother-infant
interaction
Derijcke, Eerens, & Carels, 1996). A cleft is an opening in the lip or the roof of the mouth that results from arrested midline facial development during the first trimester. Initial surgi-
State University-Sacramento,
Tel: (916) 278-6735;
BEHAVIOR
during
(CLP)
was addressed
infants.
Marya C. Endriga, California
Copyright
with
was unrelated
at 3 months
at 12 months
Clefts of the lip and/or palate (CL/P) are one of the most common birth defects in the United States, occurring in approximately one of every 1000 live births (Beaty et al., 1997;
CA, 9581 g-6007.
pairs (57 infants the CLP group
feeding
sensitivity infants
This question
to be less communicative
during
between
of avoidant
isolated
by 12 months,
sensitivity
sensitivity
mothers
with
between
of 126 mother-infant
from the CP and comparison
surgery. Although
orofacial
problems
the emotional
of age. Infants
comparison
Center, Seattle
Department
of Psychology, 6000
I Street,
Sacramento,
e-mail: [email protected]. ISSN 0163-6383
pp. 699-712 All rights of reproduction
in any form reserved.
700
INFANT
cal repair of the lip generally occurs around 3 months of age and the preferred age for palate repair is approximately 12 months old (Munro, 1995). Clefts are associated with a diverse range of medical complications including feeding problems (Clarren, Anderson, & Wolf, 1987), chronic ear infections and hearing loss (Hayes, 1994), and dental and orthodontic problems (Dahllof, UssisooJoandi, & Idelberg, 1989). This paper will focus on cleft-related feeding problems and their potential effects on the mother-infant relationship. The anatomical characteristics of cleft palate (CP) greatly hinder infants’ ability to feed. Poor intraoral suction may produce choking, emission of milk through the nose, and excessive air intake. Although several specialized feeding techniques have been developed and used with reasonable success (e.g., squeeze bottles, modified bottle nipples and other feeding appliances), many infants with cleft lip and palate (CLP) or isolated CP suffer from undernourishment and compromised growth during the first year of life (Avedian & Ruberg, 1980; Jones & Orth, 1988). The feeding process can also be extremely stressful for the parents of such infants, who often struggle to find effective feeding methods. Feedings tend to be lengthy and tiring, and may last from 45 min to l/2 h (Styer & Freeh, 1981). This is well beyond the 30 min associated with “slow feeders” in normative samples (e.g., Reau, Sentura, Lebailly, & Christoffel, 1996). In order to nourish their infants adequately, parents of infants with clefts must often become highly directive and “business-like” during feedings. There is preliminary data suggesting that such problems do not have lasting effects on the physical growth of these infants beyond the infancy period (Lee, Nunn & Wright, 1996). However, the effects of these feeding problems on socioemotional growth are largely unknown. Feeding interactions are regarded as one of the most important domains of the motherinfant social relationship during the first year (Field, 1979). Not only do feedings comprise a
BEHAVIOR
& DEVELOPMENT
Vol. 21, No. 4, 1998
large percentage of infants’ interactive opportunities in the early months of life, but the feeding situation taps many of the interactive processes critical to the formation of infant attachments to caregivers. Both the clarity of the infant’s communication of hunger, satiation, and other cues to the caregiver, and the degree of sensitivity and contingency with which the caregiver responds to these cues are expected to influence the quality of the infantcaregiver attachment relationship (Barnard, Hammond, Booth, Bee, Mitchell, & Spieker, 1989; Bowlby, 1982). Empirical support for this hypothesis has been found in studies examining the link between dyadic feeding behaviors in the early months of life and the infant’s quality of attachment at 12 months in the Ainsworth Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978). The Strange Situation is a standardized observation of separations and reunions between infants and their parents that reveals different patterns of attachment behaviors. Infants who approach the mother during reunion and show clear attenuation of separation distress upon contact with her are said to be “secure,” while those who avoid or anxiously resist contact with the mother are regarded as “insecure.” In her initial studies of this procedure with low risk infants, Ainsworth found that the mothers of securely attached 3-month old infants showed better timing of feeding initiations and terminations (relative to infants’ signals of hunger and satiation) than mothers of insecure infants. In a sample of healthy infants of socioeconomically high-risk mothers, Egeland and Farber (1984) also observed greater feeding sensitivity among the mothers of secure versus insecure infants. There is very little empirical information about the relation between infant feeding behavior and attachment. Barnard et al. found that infants’ clarity of feeding cues at 6 weeks of age was modestly and negatively correlated with ratings of attachment security, a finding that may reflect an instability in infant feeding behaviors at this early age. To our knowledge, only one study has examined the social and emotional aspects of
Feeding and Attachment
feeding interactions involving infants with orofacial clefts. Speltz, Goodell, Endriga, and Clarren (1994) observed 3 month-old infants with and without unrepaired clefts of the lip and/or palate during a feeding session with their mothers. Feeding interactions were coded with the Nursing Child Assessment of Feeding Scale (NCAFS; Barnard et al., 1989), in which trained observers recorded the presence or absence of specific infant and mother feeding behaviors. Results indicated that infants with clefts were less clear in their social cues than infants without clefts (due primarily to less smiling and less clear initiation/ satiation cues), and mothers in the CLP group showed fewer sensitive responses to their infant’s cues than mothers in the CP and comparison groups. The long-term implications of these findings for the quality of the motherinfant relationship could not be ascertained in this cross-sectional study. It might be anticipated, however, that the feeding interactions of mothers and infants with CL/P would be influenced by the surgical correction of the cleft lip or cleft palate. The current study extends the work of Speltz et al. (1994) by conducting a follow-up assessment at age 12 months of the 41 infants in that sample, plus an additional 85 subjects who were subsequently enrolled in an ongoing longitudinal investigation (total N = 126). Change in the feeding interactions of dyads containing infants with and without clefts of the lip and/or palate was examined over a 9-month period (ages 3 to 12 months). We also examined the relation between feeding interaction and quality of attachment at 12 months in both groups. Attachment quality as observed in the Strange Situation is arguably one of the best single indicators of social-emotional development in early childhood, at least in high risk samples when caregiving environments are relatively stable (Greenberg, in press); thus, attachment classification was our first-year outcome measure of psychological growth. Two specific aspects of feeding interaction were examined-infant feeding cues and maternal sensitivity-because of their the-
701
oretical relevance to the formation of attachment. Behaviors conceptually related to these constructs are targeted by two NCAFS subscales, Clarity of Cues and Sensitivity to Cues, respectively. These subscales were the focus of our analyses. The following questions and hypotheses were addressed: Is there change in the quality of motherinfant feeding behaviors during the Jirst year of life? Does change vary with diagnosis (clef vs. non-clefr)? Is change affected by “early” or “late” clefr palate surgery? Between 3 and 12 months of age, we anticipated greater positive change in the cleft group than in the noncleft comparison group (i.e., a diagnosis by time interaction), due to the significant changes in medical status experienced by infants with clefts during the first year. These include repair of the cleft lip in all of the infants with CLP during this time period, and for some infants with clefts, repair of the cleft palate as well (about 40% in our cleft sample). Although these surgical procedures are known to produce feeding complications in the immediate post-surgery period (Berkowitz, 1994), they eventually reduce oral-motor dysfunction. For infants with CLP, surgery may improve facial expressiveness (e.g., a more typical smile or grimace), therefore increasing the clarity of feeding cues. Coupled with mothers’ increasing mastery of cleft feeding techniques, these infant factors should promote greater maternal sensitivity during feeding at 12 months than 3 months. Another question was whether the occurrence or nonoccurrence of cleft palate surgery prior to 12 months was related to improved feeding interactions. We hypothesized that infants having “early” cleft palate repair (i.e., prior to 12 months) would have better infant and mother NCAFS scores than those having later repair. Is feeding interaction related to the quality (type) of attachment to mother? Ainsworth et al. (1978), in their home observations of nonimpaired infants at 3 months of age, found that the mothers of avoidant infants showed less “synchronous” interactions with their infants than mothers of secure infants, and less func-
702
INFANT
tional handling and responsiveness to crying than mothers of both secure and resistant infants. We therefore hypothesized that the mothers of infants with avoidant attachment patterns-both cleft and non-cleft-would show the fewest sensitive behaviors among the three major attachment groups (secure, avoidant, and resistant). No hypothesis was tendered about the relation between infant clarity of cues and attachment, as infant characteristics in normative samples are not expected to influence attachment directly, but rather to do so indirectly by facilitating or hindering mothers’ efforts to provide sensitive care (Speltz, Endriga, Fisher, & Mason, 1997). On the other hand, the extraordinary limitations imposed by orofacial clefts on infant feeding behavior might enhance the direct effects of infant characteristics on attachment quality. Does maternal sensitivity during feeding predict attachment among infants with clefts, after controlling for cleft diagnosis? In a previous study involving the current sample of infants with clefts, infants with CP were found to be at greater risk of insecure attachment than infants with CLP (Speltz, Endriga, Maris, & Jones, personal communication, 1997). If, as hypothesized above, maternal sensitivity during feeding is also predictive of attachment, it is important to determine whether maternal feeding behaviors offer predictive value after considering the infant’s cleft diagnosis. Finally, this study also sought to obtain important descriptive information about length and methods of feeding for cleft group infants relative to the comparison group infants, and the relation of these variables to both feeding interaction and attachment.
METHOD
The participants were 126 infants and their mothers. Twenty-nine of the infants had CLP
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& DEVELOPMENT
Vol. 21, No. 4, 1998
and 28 infants had CP. Infants in the cleft groups were consecutive, eligible referrals to a craniofacial program at a children’s hospital in a metropolitan area. Infants with more extensive birth defects were excluded, as were infants with other complicating prenatal or peri-natal factors (i.e., prematurity, twinning, maternal chemical dependency, post-natal trauma). The non-impaired comparison group (COMP) consisted of 69 healthy, typically developing infants and their mothers. COMP group infants were recruited through pediatric clinics and community centers and were enrolled in the study if they matched infants with clefts with respect to age, gender, ethnicity, maternal age, socioeconomic status, parity, and parent marital status. The first visit (“Time 1”) occurred prior to the CLP infants’ initial lip repair, at approximately 3 months of age (M = 2.9 months, SD = 0.6). The average maternal age at Time 1 was 27 years (SD = 6). One hundred-seven (85%) of the infants were Caucasian, 6 (5%) were African-American, 4 (3%) were Asian, 1 (1%) was Hispanic, and 8 (6%) had multi-ethnic backgrounds. Approximately half of the infants were female (49%). Forty-two percent of the mothers were primiparas. Eighty-three percent of the households had two parents. Families were of middle socioeconomic status (M = 3.1, SD = 1.2) as measured by the Hollingshead 4-factor Index (Hollingshead, 1975).’ No si gniticant group differences between the comparison and combined cleft groups were found on any background variable. There were significantly more females in the CP group (75%) than in the CLP group (31%),x2(1)= ll.l,p<.OOl,whichisconsistent with population gender differences for these disorders. The follow-up assessment (“Time 2”) was conducted, in most cases, within 2 weeks of the infant’s first birthday (M = 12.3 months, SD = 0.6). One hundred-sixteen dyads participated at Time 2. Ten dyads failed the followup assessment (2 CLP, 4 CP, 4 COMP). Reasons for this attrition included moving, inability to contact the family, and dissatisfaction
Feeding and Attachment
with the study. The 10 failed cases were found to have lower SES, F(1, 114) = 5.8, p c .05, and younger maternal ages, F( 1, 114) = 7.8, p < .Ol than the remaining sample. Within the remaining sample, there were no differences between the combined cleft group and the comparison group on child age, child ethnicity, child gender, maternal age, parity, SES, or marital status. As at Time 1, child gender was the only background variable that differed between the two cleft groups. Again, there were significantly more females in the CP group than in the CLP group x2( 1) = 10.47, p c .OOl). Four additional subjects were lost for some analyses because of videotape failure (1 CLP dyad), incomplete feeding sample (1 COMP dyad, 1 CLP dyad), and unclassifiable attachment (1 CLP dyad with developmental delay).
Measures Assessment
of Feeding
The quality of mother-infant interaction during feeding was measured with the NCAFS. The NCAFS contains 76 dichotomous items in which the presence or absence of a desired parent or infant feeding behavior is indicated by a trained coder. The items are grouped in relation to four subscales pertaining to the parent (sensitivity to cues, response to distress, social-emotional growth fostering, and cognitive growth fostering), and two subscales related to the infant (responsivity to parent, clarity of cues). Subscale and total scores reflect the sum of items in which a desired feeding behavior was observed to occur. Validity and reliability data are reported in Barnard et al. (1989), with Cronbach’s alphas of .73 for infant total scores, .83 for parent total scores, and alphas for specific subscales ranging from .56 to .69. In this study, two subscales were selected for analysis: infant Clarity of Cues and maternal Sensitivity to Cues. These subscales were chosen because they are the most relevant to the theoretical and empirical asso-
703
ciations between feeding and attachment described earlier, and they were shown by Speltz et al. (1994) to discriminate one or both cleft groups from the comparison group. The Clarity of Cues scale contains items such as “child signals readiness to eat” and “child smiles or laughs during feeding.” Examples of Sensitivity to Cues items include “parent comments verbally on child’s hunger cues prior to feeding” and “parent does not offer food when child looks away.” Alphas obtained from the current data set for Clarity of Cues and Sensitivity to Cues were, respectively, .65 and .59 for Time 1, and .54 and .40 for Time 2. All coders were trained through the Nursing Child Assessment Satellite Training program (NCAST) at the University of Washington (Seattle, WA). The same NCASTtrained coder coded the majority of interactions at Time 1 and Time 2. Two coders served as secondary or reliability coders. Interrater reliability was established for each NCAFS item for 33% of the sample. At Time 1, mean percent agreement across all items was 91.2% (mean kappa = .65) and at Time 2, mean percent agreement was 90.6% (mean kappa = .60).
Measurement
of Attachment
at Time 2
Videotapes of the Strange Situation (SS; Ainsworth & Wittig, 1969) were observed by two graduate student coders supervised by Robert Marvin at the University of Virginia. Coders were blind to all aspects of the study. Although in the CLP group some scarring and nasal distortion were potentially visible, postcoding interviews with the coders indicated that facial impairments were unnoticed in all but a few infants; the coders reported being unaware of the specific groups under study. Infant behavioral patterns in the SS were classified into four groups: Avoidant (A), Secure (B), Resistant (C), and Disorganized (D), as described in Ainsworth et al. (1978) and Main and Solomon (1990). However, only one cleft group infant received a D classification, so this child was “force classified” into its 3-way cat-
704
INFANT
egory (B) for the purposes of this study. All coder disagreements and all infants receiving D classifications by either coder were conferenced with R. Marvin. All participants were coded by both coders. There was 83% agreement and a Cohen’s kappa of 60 for the 3group classification. For dichotomous classification (secure, insecure), there was 82% agreement and a kappa of 55. In the same sample of infants described here, Speltz et al. (1997) found that diagnostic groups (cleft versus comparison group infants) did not differ significantly in their 12-month attachment status.
Procedure
Time 7 Assessments were scheduled to coincide with each infant’s typical period of alertness and hunger. After signing a consent form approved by the hospital’s Institutional Review Board, mothers participated in a semistructured interview with the experimenter followed by brief unstructured mother-infant play tasks and a standardized infant development assessment (not reported here). Infants were fed when hungry. The room was equipped with a cushioned rocker and straight-backed chairs, magazines, and a screened-off video camera. An observation room with a mirrored window was situated approximately 10 feet from the chairs and contained a second video camera and a female videotaper. Mothers were shown the observation room and introduced to all research staff prior to the assessment. Towards the end of the visit, the infant’s photograph was taken and mothers filled out a questionnaire packet while their infants slept or were cared for by research staff.
Time 2 Following a second interview to update medical and family information, mothers and
BEHAVIOR
& DEVELOPMENT
Vol. 21, No. 4,1998
infants participated in the Strange Situation. Then, the mothers and infants participated in feeding and play interactions and infants were given a developmental exam and photographed. Afterwards, the mothers completed the questionnaire measures.
RESULTS
Length and Method
of Feedings
Time 1 Complete feeding observations were obtained for 125 dyads at Time 1 (1 COMP subject did not complete the feeding task). The mean feeding length at Time 1 was 18 min (SD = 9.3, range = 4-55 min). Group differences were found in length of feeding, F (2, 123) = 3.2, p c .05. Feedings in the CLP (M = 19.9, SD = 10.9) and CP (M = 20.7, SD = 12.7) groups were longer than in the comparison group (M = 16.4, SD = 6.3). Length of feeding was uncorrelated with NCAFS maternal sensitivity at Time 1. However, there was a significant correlation between Time 1 infant clarity of cues and length of feeding (r = .18, p < .05), indicating that infants with more frequent indicators of clear feeding cues had longer feeding sessions. Follow-up analyses indicated that this relationship was only significant within the CLP group (r = .42, p < .05). Group differences were also present in the method of feeding at Time 1. Only 3 (5.4%) infants in the combined cleft groups were breast-fed compared with 39 (57.4%) breastfed comparison group infants; 53 (94.6%) cleft group infants were bottle-fed, compared with 29 (42.6%) bottle-fed comparison infants, x2 = (1) = 37.07, p c .OOl. One infant with CLP was gavage (“tube”) fed. As method of feeding was confounded with diagnosis (cleft versus comparison group status) and there were very few breast-fed infants with clefts, relations between feeding method and other variables were examined only within the comparison group. T-tests comparing the
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INFANT
COMP infants demonstrating clearer cues than CLP infants [t(42) = -2.68, Bonferroni correctedp < .0167]. No significant diagnostic group differences were detected at Time 2. T-tests were used to compare the Time 2 feeding interactions of cleft group infants receiving cleft palate surgery either before (n = 20, 40%) or after (n = 30, 60%) the Time 2 assessment. No significant differences in infant clarity of cues or maternal sensitivity were found. Relations between Attachment Cleft Group
Feeding and
infants
Infants with CLP and CP were combined to form a single cleft group for these analyses, due to insufficient cell sizes when cross-tabulating the 3 attachment categories (secure, avoidant and resistant) and both cleft diagnoses. Table 2 summarizes the descriptive statistics for feeding interaction scores by attachment classification for the cleft group. Within the cleft sample, results of a repeated measures analysis of vari-
14
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& DEVELOPMENT
Vol. 21, No. 4, 1998
ante for maternal sensitivity by attachment classification revealed a significant interaction of attachment by time [F (2,45) = 3.38, p < .05] and a significant main effect of time [F (1,45) = 2 1.94, p c .OOl]; maternal sensitivity decreased over time. Follow-up analyses of the simple effects of attachment classification at each time point revealed that maternal sensitivity at Time 1 was unrelated to 12-month attachment classification. At Time 2, there was a significant effect of attachment on maternal sensitivity scores, F (2,47) = 4.42, p < .05. Post-hoc comparisons indicated that avoidant infants had significantly lower maternal sensitivity scores than secure infants [t(37) = -3.29, Bonferroni corrected p < .0167]. Follow-up simple effects analyses of time for each attachment classification indicated that maternal sensitivity decreased over time significantly for avoidant [F(1,45)=12.51,p<.OOl]andresistant[F(l, 45) = 5.91, p < .05] infants. This finding is shown in Figure 2. Results of a repeated measures analysis of variance for infant clarity of cues found a significant main effect of time [F (1,45) = 40.34, p < .OOl], with clarity increasing over time.
1
10 Time 2
Time 1 FIGURE 1 NCAFS
clarity of cues scores over time by diagnostic group (full sample).
Feeding
707
and Attachment
ment (1) = 4.9, p c .05, R = -.20). Diagnosis and change in maternal sensitivity each resulted in the same overall level of correct case classification (69%). Knowing both diagnosis and change in maternal sensitivity improved prediction to 77% overall (90.1% for secure cases, 46.7% correct for insecure cases). The odds ratios in this regression model indicated that insecure attachment was 4.4 times more likely than secure attachment for infants with cleft palate, and .71 more likely with each unit of negative change in maternal sensitivity.
No significant main effect of attachment or time by attachment interaction was detected. In order to determine the relative power of cleft diagnosis and maternal sensitivity change scores to predict attachment, a logistic regression was conducted using two-way attachment classification (secure versus insecure) as the dependent variable. Covariates were entered hierarchically with cleft diagnosis first and change in maternal sensitivity second in the initial analysis; the process was then reversed in order to determine which variable accounted for the greatest variance. Both diagnosis and change in maternal sensitivity accounted for significant variance in the logistic regression equation, whether entered first or second, indicating that each contributed independently to the prediction of attachment status. When cleft diagnosis alone was entered in the logistic regression equation, it predicted attachment status [model x2 (1) = 5.3, p c .05, R = .21. When entered second, after the maternal sensitivity change score, diagnosis significantly improved the model (improvement x2 (1) = 4.6, p < .05, R = .20). When only change in maternal sensitivity was entered into the regression equation, it also predicted attachment status [model x2 (1) = 5.2, p < .05, R = -.21]. When entered second, after diagnosis, change in maternal sensitivity significantly improved the model x2 improve-
Comparison
Group
Infants
Table 3 summarizes the descriptive statistics for feeding interaction scores by attachment classification for the comparison group. No significant main effects of attachment classification or attachment by feeding interactions were detected for maternal sensitivity or infant clarity of cues.
DISCUSSION The results of the current study differ from Speltz et al.‘s (1994) findings, in that fewer differences in feeding interactions were revealed between the cleft and comparison groups in the
TABLE 2 Attachment
classifications
and NCAFS subscale Time
M
scores within
the Cleft Group
1
Time 2
SD
M
SD
Maternal Sensitivity A (n = 6)
13.50
1.38
10.33
1.51
6 (n = 33)
13.00
1.95
12.24
1.28
C (n = 9)
13.67
2.06
11.89
1.97
0.63
Infant Clarity of Cues
Note
A =
A (n = 6)
8.83
3.25
14.00
B (n = 33)
10.73
2.56
13.39
1.44
c (n = 9)
10.78
1.64
13.56
2.01
avoidant, B = secure, C = ambivalent/resistant
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Time 2
Time1 FIGURE 2
NCAFS
sensitivity
scores over time by attachment classification
present sample. Speltz et al.‘s (1994) results were based on a smaller sample containing the fust 41 subjects enrolled in the current sample of 126, assessed only at Time 1. The present findings are based on a larger sample of families, participating in both the Time 1 and Time 2 assessments, who had higher SES and older maternal age than those not attending the Time 2 assessment. In the Barnard et al. (1989) standardization sample, mothers with more education (which, along with occupation, comprises SES) were found to have higher NCAPS scores. The Barnard study did not examine maternal age, but it might be anticipated that older mothers would be more skilled at feeding their infants due to greater maturity or more experience with infants. The NCAPS Clarity of Cues scale contains items referring to infants’ hunger and satiation cues, alertness and activity level, and various social behaviors such as eye contact, vocalization and smiling directed at the mother. In the current study, the CLP group showed signifi-
(clefts only).
cantly fewer of these behaviors during feeding at age 3 months than comparison group infants. This finding is consistent with previous reports of greater passivity and less facial expressiveness among infants with clefts than those without clefts (Starr, Chinsky, Canter, & Meier, 1977). However, at 12 months, the cleft and comparison groups were indistinguishable, indicating that the infants with CLP had “caught up” in this communicative aspect of feeding. Unfortunately, our data do not provide a ready explanation for this improvement among the CLP group infants. It cannot be attributed to either cleft lip or cleft palate surgery, as both cleft groups showed equivalent positive change (thus eliminating cleft lip surgery as uniquely contributory) and clarity of cue scores did not vary by date of cleft palate surgery (before or after the 12 month feeding assessment). At this point we can only speculate that either familiarity with mothers’ feeding style or an attenuation of risk factors common to both cleft groups-such as poor
Feeding and Attachment
709
TABLE 3 Attachment
classifications
and NCAFS subscale scores within the comparison Time 1 M
group Time 2
SD
M
SD
Maternal Sensitivity A (n = 12)
13.75
1.60
11.83
1.90
B (n = 46)
14.04
1.30
12.35
1.75
C (n = 6)
14.33
1.63
12.50
1.98
Infant Clarity of Cues A(n=
Note
12)
10.92
1.62
13.17
1.47
B (n = 46)
12.02
2.08
13.57
1.34
C (n = 6)
12.00
1.41
14.17
.9a
A = avoidant, B = secure, C = ambivalentkristant
weight gain or elevated risk of illness-contributes to these infants’ improving feeding communications over time. Observed maternal sensitivity during feeding at 3 months did not predict attachment within the cleft group. However, a concurrent relation was found between attachment and maternal sensitivity at 12 months, and change in maternal sensitivity between 3 and 12 months was predictive. As hypothesized, the mothers of insecure-avoidant infants showed fewer sensitive behaviors than mothers of secure infants, and greater negative change in maternal sensitivity than mothers of secure infants. The mothers of avoidant infants with clefts showed a more pronounced manifestation of the trend found in all groups for declining sensitivity scores over time. Conversely, the mothers of secure infants with clefts were more likely to show behaviors that opposed this trend. Thus, while 84% of mothers in the avoidant group showed negative change in sensitivity, only 50% of mothers in the secure group did so. The logistic regression analysis indicated that change in maternal sensitivity was as important as cleft diagnosis (CLP or CP) in predicting the dichotomous attachment status of infants with clefts (secure or insecure). Both variables contributed independently to the prediction of attachment and
together they provided a better prediction of attachment status than either alone. Infants’ clarity of cues was not predictive of attachment at either time point. It is possible that the significant improvement in clarity of cues shown by cleft group infants was associated with mothers’ change in maternal sensitivity. However, in a post hoc analysis that addressed this question, we found no association between change in clarity of cues scores and change in maternal sensitivity (r = .005). Thus, there is no evidence that change in infant feeding behaviors affected attachment indirectly by way of maternal sensitivity. What other factors might account for change in maternal sensitivity, if not infant feeding behavior? Cleft surgeries were not explanatory, as both cleft groups showed equivalent declines in maternal sensitivity, and maternal sensitivity scores were unrelated to cleft palate surgery date. As decline in sensitivity was most pronounced in the insecureavoidant group, we considered the maternal characteristics that have been associated with avoidant infants in other samples. One prominent factor is maternal mood (depressed and/ or anxious), which has been shown to distinguish the mothers of secure and avoidant infants in high social risk samples (e.g., Lyons-Ruth, Botein, & Grunebaum, 1984;
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Stevenson-Hinde & Shouldice, 1995). Another factor is maternal personality style. There is some evidence that mothers of avoidant infants are more likely than other mothers to adopt a defensive posture in their reports of self and family emotions and conflict; in other words, they attempt to minimize or avoid negative emotions (Spieker & Booth, 1988). In order to explore these possibilities, a post hoc analysis was undertaken in which the association between change in sensitivity and mothers’ self-reports of parenting-related stress and negative mood was examined in the cleft group (using the Parenting Stress Index parent score; see Abidin, 1990). Significant relations were found between change in sensitivity during feeding and parenting stress at 3 months (I = .44, p < .Ol) and 12 months (r = .30, p < .04), indicating that higher stress scores were associated with more positive change in sensitivity during feeding among the mothers of infants with clefts. In the comparison group, there were no significant relations between parenting stress and maternal sensitivity. This post hoc finding suggests a hypothesis for further investigation: Among the mothers of infants with CL/P, change in maternal sensitivity during feeding is related to selfreports of stress and negative mood states, with positive change more likely for those mothers who openly acknowledge the stress associated with caring for an infant with this type of congenital defect. This study has several limitations that render some findings tentative. Small sample size, which is an everpresent problem in the study of rare medical disorders, prevented the analysis of attachment classification by specific cleft diagnosis. The effects of small sample size were only partially offset by combining the cleft groups together for the attachment analyses. There were still very small numbers of infants with insecure-avoidant and insecure-resistant attachments (n’s of 6 and 9, respectively). We can place the most confidence in analyses that used the dichotomous categorization of attachment (secure versus insecure). Another problem is the low internal consistency of the
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Vol. 21, No. 4, 1998
NCAFS subscales selected for analysis, particularly the maternal sensitivity subscale at 12 months (a = .40). In Barnard’s et al. (1989) standardization sample, the feeding subscale alphas were also relatively low and these authors recommended use of the parent and child total scores, at least for clinical purposes. However, we elected to prioritize the specific theoretical match between the scales that were used and attachment theory. The total parent and child scales were felt to be too broad for our purposes. In future studies with larger samples of infants with clefts, factor analysis of the NCAFS may be necessary to derive statistically sound scales for use in this population. It is also important to note that the findings regarding maternal sensitivity and avoidant attachment are essentially concurrent and therefore the direction of effect between these two variables is uncertain. Decline in maternal sensitivity could have promoted avoidant attachment or vice-versa. Nevertheless, our findings suggest that there is potential utility in the clinical observation of mother-infant feedings in the cleft population, particularly if methods like the NCAFS are used to detect changes in maternal sensitivity over the latter half of the first year. Further research to replicate these findings is needed before clinical applications of these findings are considered. It is also important to demonstrate that the outcome measure used herein-attachment status at 12 months-is indeed predictive of subsequent psychological outcomes in the cleft population. Work is underway in our longitudinal project to test this hypothesis with the current sample of children at school entry. Acknowledgments: This research was supported by NICHHD grant ROl-HD25987-08. We would like to thank Kris Barnes, Lynne Foss, and Jacquie Stock for their coding of the NCAFS data; Robert Marvin, Maria Morog, Tom O’Connor for their coding of attachment data; and Sterling Clarren and Wendy Mouradian for the referral of patients to this research
feeding and Attachment
project. We would also like to thank the families who have participated in this research.
NOTES 1. Updated additions to Hollingshead’s categories were provided by T. M. Achenbach (personal communication, 1997).
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and a new direction. Journal of Developmental and Behavioral Pediatrics, 17(3), 149-153. Speltz, M. L., Endriga, M. C., Fisher, F? A., & Mason, C. A. (1997). Early predictors of attachment in infants with cleft lip and/or palate. Child Development, 68, 12-25. Speltz, M. L., Goodell, E. W., Endriga, M. C., & Clarren, S. K. (1994). Feeding interactions of infants with unrepaired cleft lip and/or palate. Infant Behavior and Development, 17(2), 13 l140. Spieker, S., & Booth, K. (1988). Maternal antecedents of attachment quality. In J. Belsky & T. M. Nezworski (Eds.). Clinical implications of attachment (pp. 95-135). Hillsdale, NJ: L. Erlbaum & Associates.
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Starr, I’., Chinsky, R., Canter, H., & Meier, J. (1977). Mental, motor, and social behavior of infants with cleft lip and/or palate. Clef Palate Journal, 14, 140-147. Stevenson-Hinde, J., & Shouldice, A. (1995). Maternal interactions and self-reports related to attachment classifications at 4.5 years. Child Development, 66, 583-596. Styer, B. S. & Freeh K. (1981). Feeding infants with cleft lip and/or palate. Journal of Obstetrics, Gynecology, and Neonatal Nursing, 10, 329-332.
30 December
1997;Revised 08 May 1998n