Infant sleep moderates the effect of infant temperament on maternal depressive symptoms, maternal sensitivity, and family functioning

Infant Behavior and Development 57 (2019) 101343

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Infant sleep moderates the effect of infant temperament on maternal depressive symptoms, maternal sensitivity, and family functioning

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Stephanie H. Parade⁎, Kristyn Wong, Renee Belair, Susan Dickstein, Ronald Seifer E. P. Bradley Hospital and the Warren Alpert Medical School of Brown University, United States

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ABSTRACT

Keywords: Infant temperament Infant sleep Maternal sensitivity Postpartum depression Family functioning

Observed infant temperamental difficulty and infant sleep efficiency and sleep variability were examined as predictors of maternal depressive symptoms, maternal sensitivity, and family functioning. Eight observations at 8-months postpartum were used to assess infant temperament, and actigraphy was used to measure infant sleep for 1-week at the time of the 8-month assessment. Structured clinical interviews were used to assess maternal depressive symptoms between 5 and 12 months postpartum and at 15 months postpartum, and observational assessments were used to assess maternal sensitivity and family functioning at 15 months postpartum. Variability in infant sleep moderated the effect of infant temperament on maternal depressive symptoms, maternal sensitivity, and family functioning. Infant temperament was positively associated with maternal depressive symptoms when variability in infant sleep efficiency was high, but not when variability in infant sleep efficiency was low. Likewise, infant temperament was negatively associated with maternal sensitivity and family functioning when variability in infant sleep efficiency was high, but not when variability in infant sleep efficiency was low. Results underscore the importance of infant sleep for maternal and family health.

1. Introduction It has long been recognized that individual infant characteristics, such as temperament and sleep, have the potential to influence caregiving behavior, maternal adjustment, and family wellbeing (Belsky, 1984; Cowan & Cowan, 2000; Crouter & Booth, 2003; Sameroff, 2009). Yet the conditions under which infant characteristics contribute to the caregiving context are not fully understood. Specific combinations of distinct individual factors, such as infant temperament and infant sleep may interact to explain variation in maternal and family wellbeing. The current study uses a longitudinal design to examine associations among infant temperamental difficulty, and infant sleep efficiency, infant sleep variability, and maternal depressive symptoms, maternal sensitivity, and family functioning. 1.1. Infant temperament Previous literature regarding infant temperament has offered various definitions and conceptualizations of the construct. This

⁎ Corresponding author at: Bradley Research Center, E. P. Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI, 02915, United States. E-mail address: [email protected] (S.H. Parade).

https://doi.org/10.1016/j.infbeh.2019.101343 Received 11 June 2018; Received in revised form 26 April 2019; Accepted 19 July 2019 0163-6383/ © 2019 Published by Elsevier Inc.

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study focuses on the behavioral style approach introduced by Thomas, Chess, Birch, Hertzig, and Korn (1963) which suggests that individual differences in temperament lie in an infant’s behavioral response to the demands and expectations of the environment or new social situations. Temperamentally difficult infants demonstrate high activity, high negative mood, low approach, and high distractibility, these traits are risks factors for behavior problems (Guerin, Gottfried, & Thomas, 1997), and poor social competence (Sanson, Hemphill, & Smart, 2004). As reviewed below, parents of temperamentally difficult infants may be at risk for greater parenting stress and more negative affect, which may undermine sensitive parental behavior. However, these links are complex and are often dependent on other risk factors. 1.1.1. Temperament and maternal depression Maternal depression commonly affects women during the postpartum period, and there is evidence that infant temperamental difficulty is associated with maternal depression (Beck, 2001). Maternal self-reports of depression are significantly correlated with infant temperamental difficulty (Britton, 2011), and significant differences in maternal reports of infant temperament have been observed between depressed and non-depressed mothers, such that depressed mothers rate their infants as more temperamentally difficult (McGrath, Records, & Rice, 2008). Mothers with more temperamentally difficult infants may have lower parenting selfefficacy (Cutrona & Troutman, 1986) and greater parenting stress (Gelfand, Teti, & Radin Fox, 1992). Yet not all mothers with temperamentally difficult infants report depressive symptoms, suggesting that other factors potentially moderate these links. Indeed, Crockenberg and Leerkes (2003b) demonstrated that high paternal acceptance in the mother’s own childhood buffered mothers from the effect of infant temperament on maternal depressive symptoms. Infant temperamental reactivity was positively associated with maternal depressive symptoms only when mothers recalled low paternal acceptance in their own childhoods (Crockenberg & Leerkes, 2003b). Related, a negative infant temperament was positively associated with parental depressive symptoms when parents reported low co-parenting support from their partner, but not when parents reported high co-parenting support (Solmeyer & Feinberg, 2011). Additional research is needed to understand factors that moderate associations among infant temperament and maternal depression. 1.1.2. Temperament, maternal sensitivity, and family functioning Maternal sensitivity is widely recognized as a robust predictor of child social-emotional wellbeing including secure infant attachment (Ainsworth, Blehar, Waters, & Wall, 1978), social competence (Leerkes, Blankson, & O’Brien, 2009), and cognitive development (Stams, Juffer, & van IJzendoorn, 2002). Sensitive mothers accurately identify, interpret, and contingently respond to their infant’s cues via consistent and predictable interactions. These responses are believed to provide external regulation and modulation of infant affect which support the foundation for later self-regulation capacities (Bernier, Carlson, & Whipple, 2010; Spanglar, Schieche, Ilg, Maier, & Ackermann, 1994; Sroufe, 2000). Although maternal sensitivity is often examined as a predictor of infant temperament, there is evidence that infant temperament also has the potential to undermine maternal sensitivity and other aspects of parenting, particularly within more at-risk samples including samples of women with a history of depression and families of low socioeconomic status (Goodman, Bakeman, McCallum, Rouse, & Thompson, 2017; Paulussen-Hoogeboom, Stams, Hermanns, & Peetsma, 2007). Indeed, Crockenberg and Leerkes (2003a) suggest that a difficult infant temperament undermines parenting only in the context of other risk factors. Supporting this perspective, maternal characteristics, including parenting efficacy and cognitive and emotional reactions to infant distress, moderate associations of temperament and sensitivity (Leerkes & Crockenberg, 2002; Leerkes, 2010). Less is known about additional infant characteristics that moderate the association of infant temperament and parenting behavior. In addition to maternal sensitivity, infants develop within the context of the larger family system, and infant characteristics such as temperament have been identified as important proximal correlates of other relationships within the family system. For example, patterns of change in marital satisfaction across the transition to parenthood vary as a function of infant temperament (Belsky & Rovine, 1990), and declines in marital satisfaction were observed when spouses recalled both childhood parental rejection and high infant temperamental frustration (Parade, Leerkes, & Helms, 2013). The association of infant temperament and co-parenting behavior is also moderated by marital quality (Schoppe-Sullivan, Mangelsdorf, Brown, & Sokolowski, 2007). Taken together, this work suggests that the association of infant temperament and relationships within the family system may be moderated by other risk factors. The current study draws upon the McMaster Model of Family Functioning (Epstein, Bishop, & Levin, 1978; Miller, Ryan, Keitner, Bishop, & Epstein, 2000), that assumes that all parts of the family system are interdependent, that relationships within the family are transactional, and that family structure plays a significant role in influencing the behavior of individual family members. Thus, we focus on whole family functioning, which includes six interrelated dimensions including problem solving, communication, roles, affective responsiveness, affective involvement, and behavioral control within the family system. 1.2. Infant sleep Sleep is widely recognized as an essential component of healthy early childhood development, particularly for the development of attentional and regulatory capacities (Bernier et al., 2010). Furthermore, within the family context, infant sleep difficulties often have ripple effects on maternal and family wellbeing, through impact on parental sleep quality, parental daytime functioning, parenting behavior, and parental beliefs/cognitions about sleep (Meltzer & Montgomery-Downs, 2011; Tikotzky & Sadeh, 2009). 1.2.1. Sleep and maternal depression Cross-sectional studies find evidence of associations between infant sleep problems and poor maternal mental and physical health (Bayer, Hiscock, Hampton, & Wake, 2007). Dennis and Ross (2005) found that mothers with greater depressive symptoms were more 2

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likely to endorse greater infant night wakings and shorter infant sleep durations. In a prospective longitudinal study examining predictors of infant regulatory problems, Martini et al. (2017) also found maternal depressive disorders were associated with greater infant sleep problems reported on a structured diagnostic interview. Likewise, maternal depressive symptoms were positively associated with maternal difficulty with adaptation to infant sleep (Countermine & Teti, 2010). Although much of this prior work has focused on maternal depression as a predictor of infant sleep difficulty, infant sleep difficulty may also be a risk factor for maternal depression (Sadeh, Tikotzky, & Scher, 2010). Among mothers of infants three to six months of age, infant night wakings were associated with greater maternal depressive symptoms (Bayer et al., 2007). In older children, child sleep disruption was predictive of maternal sleep quality, and maternal sleep quality was associated with depressive symptoms (Meltzer & Mindell, 2007). 1.2.2. Sleep, maternal sensitivity, and family functioning Prior research focused on infant sleep, maternal sensitivity, and family functioning has predominantly focused on nighttime parenting behavior and infant sleep. For example, mothers with greater emotional availability (a correlate of maternal sensitivity) at bedtime reported fewer infant sleep difficulties and longer infant sleep duration (Teti, Kim, Mayer, & Countermine, 2010). Conversely, Sadeh et al. (2010) note that within typically developing samples, sleep disruptions and night waking is common even within positive mother-infant relationships that are considered responsive and available. Thus, the authors note that multiple pathways likely exist in determining the influence of parent involvement on infant sleep regulation. Together, these mixed findings allude to complex associations among these factors. Few studies have focused on infant sleep as a predictor of parenting behavior. Poor infant sleep may contribute to increased maternal fatigue and hinder a mother’s ability to engage in supportive parenting behaviors, contributing to greater overall levels of parenting stress and difficulties with parenting. Supporting this possibility, fatigue among mothers of infants and toddlers is associated with decreased parenting efficacy and parenting satisfaction and increased parental hostility (Giallo, Rose, & Vittorino, 2011). Bidirectional associations between maternal emotional availability at bedtime and infant nighttime distress have also been observed, including evidence that infant nighttime distress contributes to lower emotional availability (Philbrook & Teti, 2016). Research examining the relationship between infant sleep and maternal sensitivity outside of bedtime is limited, but prior work with older children suggests that child sleep problems contribute to declines in maternal sensitivity over time (Bell & Belsky, 2008). A few studies have examined links between infant sleep and family functioning, and results highlight the possibility of bidirectional associations of infant sleep and family functioning. Medina, Lederhos, and Lillis (2009) suggest that infant sleep disruption is a risk factor for postpartum declines in marital satisfaction, whereas, others find that martial conflict is a risk factor for infant sleep disruption (Mannering et al., 2011). Infant sleep difficulties have also been indirectly linked to parent distress and quality of co-parenting behavior (McDaniel & Teti, 2013). In older children, Kelly and El-Sheikh (2011) found bi-directional associations between marital conflict and child sleep disruption using latent variable modeling. Evidence that both marital conflict predicts increases in child sleep disruptions, and child sleep disruptions predicts increases in marital conflict over time, were found. More research is needed to further elucidate the complex associations among infant sleep and maternal and family wellbeing. 1.3. Interactive effects of infant sleep and infant temperament Prior work examining infant sleep as a moderator of associations of individual and contextual risk factors and infant outcomes underscores the importance of high-quality sleep in the promotion of optimal developmental and relational outcomes. Bordeleau, Bernier, and Carrier (2012) found a significant interaction between infant sleep duration and maternal sensitivity at 12 months in relation to behavior problems at 4 years of age, such that maternal sensitivity was negatively related to later behavior problems for infants with greater sleep duration. In a related study, Bernier, Belanger, Tarabulsy, Simard, and Carrier (2014) examined infant sleep as a moderator of maternal sensitivity and toddler social emotional outcomes at 24 months. Results indicated significant positive associations between maternal sensitivity and attachment security for infants who slept longer. Among older children, but most relevant to the current study, sleep has been found to moderate the relationship between temperament and developmental outcomes. In a sample of preschool and kindergarten children, Berger et al. (2017) found that child sleep duration moderated the relationship between multiple reports of shyness and negativity and academic achievement, suggesting that shorter sleep duration is a risk factor for poor academic performance in early childhood. Later observed sleep onset or midpoint sleep has also been found to exacerbate the effects of child negative affect on child behavior problems at 4 years of age (Cremone et al., 2017). Together these studies suggest infant sleep may play an important moderating role in the promotion of positive social-emotional and relational outcomes for parents and infants. Infant sleep may be a particularly relevant moderator of the multifaceted construct of infant temperamental difficulty on maternal and family wellbeing. For example, difficulty with infant sleep may exacerbate effects of infant negative mood and distractibility on maternal and family wellbeing by taxing the infant’s capacity for self-regulation when they are highly fatigued. However, to our knowledge no studies have examined infant sleep as a moderator of temperament effects on maternal or family wellbeing. 1.4. Current study The current study builds upon existing literature to examine relations between infant temperamental difficulty, infant sleep, and their potential joint contributions to maternal depressive symptoms, maternal sensitivity, and family functioning. This study utilizes a longitudinal design to explore the following research questions: 3

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1 Is infant temperamental difficulty associated with maternal depressive symptoms, maternal sensitivity, and family functioning? 2 Are infant sleep efficiency and infant sleep variability associated with maternal depressive symptoms, maternal sensitivity, and family functioning? 3 Do infant sleep efficiency and infant sleep variability moderate the associations among infant temperamental difficulty and maternal depressive symptoms, maternal sensitivity, and family functioning? Previous studies examining infant temperament and infant sleep have relied heavily on maternal report, yet maternal reports of child behavior may be biased by emotional dispositions and states of mind (Seifer, Sameroff, Barrett, & Krafchuk, 1994; Seifer, Sameroff, Dickstein, Schiller, & Hayden, 2004). Depressed mothers have been found to rate their infants as more temperamentally difficult (Britton, 2011; McGrath et al., 2008) and higher in negative emotionality (Huot, Brennan, Stowe, Plotsky, & Walker, 2004) than mothers who are not depressed. Furthermore, and specific to infant sleep, Sadeh, Lavie, Scher, Tirosh, and Epstein (1991) suggest that parent reports of infant and child sleep may overestimate sleep duration and related parameters. More studies utilizing objective measures of temperament and sleep are needed to clarify associations among infant temperament, infant sleep, and parenting (Scher, 2001). We address these issues by using observational and objective methods to assess infant temperament, infant sleep, maternal sensitivity and family functioning. To our knowledge, this is the first study to examine the interactive effects of infant temperament and infant sleep on maternal and family functioning outcomes. 2. Material and methods 2.1. Participants One hundred and thirty-one families from the Goodness of Fit (GOF) study comprise the sample for the current report. Families were recruited prenatally from the main obstetrics hospital in a metropolitan area in the northeastern United States that accounted for approximately 90% of the births in the region. Families were approached during childbirth education classes, given a brief presentation about the study, and interested families were contacted by telephone to arrange a prenatal enrollment visit. Families were followed longitudinally through 30 months postpartum with assessments at prenatal, 4 months, 8 months, 15 months, and 30 months of age. The current report focuses on temperament and sleep data collected at the 8-month assessment, and maternal depression, sensitivity and family functioning data collected at the 15-month assessment. At the time of the infant’s birth 160 families were enrolled in the GOF study. At 8 months of age, temperament observations and sleep data were available from 131 infants who comprise the sample for the current report. For the 131 families who were enrolled at 8 months of age and comprise the sample for data analysis, their infants included 68 (52%) boys and 63 (48%) girls. Seven of the infants were Black, 9 Hispanic, 1 Asian, and 5 other race. The remaining 109 infants were White, non-Hispanic. The majority of mothers (n = 104) were married and living with their spouse, 18 were single or divorced and living with a partner, and 9 were single or divorced and not living with a partner. Hollingshead (1975) 4-factor SES scores were computed from the education and occupation scores of the two adults in the household at study entry. For those families where only the mother was in the household, her education and occupation determined the SES classification. Lower scores indicate higher SES. Most of the sample was middle or upper SES: 120 had Hollingshead (1975) SES of 1-3. Six mothers had less than a high school education, 14 were high school graduates, 34 had some college, and 77 had a 4-year college degree or higher. The GOF study was focused on understanding infant development in family risk contexts, therefore families were oversampled for maternal depression: Slightly more than half of mothers (n = 70) had a lifetime history of major depression assessed using the Structured Clinical Interview for DSM-IIIR (Spitzer, Williams, Gibbon, & First, 1990) in the prenatal period and the Longitudinal Interval Follow-up Evaluation (LIFE; Keller et al., 1987) in the postpartum period. Fifty-nine of the mothers with a lifetime history were depressed prior to pregnancy, 21 were depressed during pregnancy, and 33 were depressed in the first year postpartum. 2.2. Infant temperamental difficulty: 8 months postpartum A series of 8 videotaped observations of the mother and her infant in the home were scheduled at 8 months of age. The 8 observations were typically completed within a 4-week period around the assessment age (some families completed fewer than 8 observations, see details below). Assessments were scheduled for times that the infant was expected to be awake, alert, and interactive, thus visits typically occurred mid-day following a nap. A single research assistant was assigned to each family for the duration of the study and was responsible for videotaping all of the assessments. Each observation at 8 months included at least 10 min of three situations: mothers in close proximity with infant, infant alone, and mother caretaking behavior. The activities during which the mothers were in close proximity with the infant were intentionally mother driven activities (predominantly play activities across all 3 waves of assessment), rather than experimenter driven activities, to capture infant behavior during naturally occurring mother-infant interactions in the home. Likewise, the activities when the infant was alone were intentionally infant driven activities and were also predominantly play activities across all 3 waves of assessment. Efforts were made to capture these different situations during naturally occurring interaction, if these situations did not naturally occur during the observation mothers were prompted to engage in one of the three types of interaction so that all dyads engaged in all three types of interaction. The video recording lasted approximately 45 min per session. Given our interest in understanding how a child’s behavioral style naturally develops in context, we intentionally designed our observational assessment to occur in the home rather than a laboratory setting. 4

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Infant behavior during each of the video recordings was scored using the Temperament Adjective Triad Assessment (Seifer et al., 1994), which includes 14 bipolar items defined by a triad of adjectives at each pole. Temperament domains assessed in the 14 items include mood, approach, activity, intensity, and distractibility. Example items include “Happy/Jubilant/Cheerful — Sad/Blue/Unhappy” and “Content/Satisfied/Comfortable — Fussy/Upset/Cranky”. Research assistants who did not conduct the home visits with the family scored the 14 temperament items on a nine-point scale. Rater reliability was .80 or above (intraclass correlation) and was established on four sets of 10 videotapes per set that were double coded by a lead rater and the rater in training. The mean of the 14 Temperament Adjective Triad Assessment items was used to derive a Total Difficulty score for each videotaped observation. A high Total Difficulty score reflected an infant with high activity, high negative mood, low approach, and high distractibility. Scores for the total session (temperament across the 3 situations including mother-infant, infant alone, and caretaking) were used. Alpha coefficients for the Total Difficulty Score from the 14 items was .86 at 8 months. Total Difficulty scores for each videotaped observation were then averaged across the set of 8 observations to compute an 8-observation aggregate score within each wave of assessment. Aggregate scores were not computed for those families with less than 4 observations. All of the families in the current report completed enough observations to compute an aggregate score and most families completed all 8 observations at each wave of assessment (92% at 8 months). Possible scores ranged from 14-126. As demonstrated in our previously published work (Parade, Dickstein, Schiller, Hayden, & Seifer, 2015), internal consistency reliability estimates of the 8-observation aggregates were high (.81 at 8 months). 2.3. Infant sleep efficiency and sleep variability: 8 months postpartum Infant sleep was measured objectively using an actigraph (Mini-Motion Actigraph, Ambulatory Monitoring, Inc., Ardsley, NY) worn on the infant’s ankle at 8 months of age. Actigraphy has been validated to measure of infant sleep-wake patterns in naturalistic settings (Sadeh, 2015). Mothers were asked to monitor infants’ sleep, by recording sleep in a sleep diary and attaching the actigraph to the infants’ ankles, for a period of 7 days. Mothers recorded the time that infants were put to bed and got out of bed for the day, times the infant was asleep, caretaking behaviors, and possible disruptions in the actigraph (e.g., taken off during baths, external motion). If the first week of actigraph monitoring did not yield valid and useable data, families were given an extra week to monitor infant sleep. Sleep measures were utilized in the current study when they included of at least 5 nights of usable actigraphy data. The current report focuses exclusively on nighttime sleep, and does not include assessments of daytime sleep. Maternal reports of infant evening bed time and morning wake time recorded in the sleep diary were used to determine the period of nighttime sleep. Infant activity was measured in 1-minute epochs. Actigraphy data was then scored using a validated algorithm (Sadeh et al., 1991), to generate two summary scores for data analysis including infant sleep efficiency and variability in infant sleep efficiency. Infant mean sleep efficiency was the percentage of epochs that the infant was sleeping divided by the total number of epochs. Possible scores range from 0 to 1. Night-to-night variability in infant sleep efficiency was the standard deviation of infant sleep efficiency across the days wearing the actigraph. The sleep efficiency algorithm does not include sleep latency. 2.4. Maternal depressive symptoms: 5–12 months postpartum Mothers completed the Structured Clinical Interview for DSM-IIIR (Spitzer et al., 1990) prenatally and the Longitudinal Interval Follow-up Evaluation (LIFE; Keller et al., 1987) every six months in the postpartum period to capture symptoms and diagnostic criteria for major depression on a month by month basis. At the time of each LIFE interview, a psychiatric symptom rating (PSR) was assigned for each month considered in the interview to capture the severity of depressive symptoms. A score of 1 indicates no symptoms, scores of 2–4 indicate sub-syndromal symptoms of increasing severity and impairment, and scores of 5 and 6 indicate that criteria for DSM disorder are met with the higher score indicating extreme impairment. Although DSM-IV was available at the time of this study, a desire to compare and/or combine this sample with other samples previously collected in our laboratory led us to use clinical interviews designed for DSM-IIIR. Depression criteria in the DSM, as well as in the SCID interview instrument, were not changed in any meaningful way from version IIIR to version IV. This choice also maximized compatibility with the LIFE instrument to capture symptoms and diagnostic criteria beyond the initial clinical interview. Clinical interviewers received centralized SCID training by the DSM-IV depression workgroup, and achieved the reliability standard (.80 or above). The mean PSR score was computed for the severity of maternal depressive symptoms between 5 and 12 months postpartum (average of the 8 monthly PSR scores). Possible scores ranged from 1 to 6. 2.5. Maternal depressive symptoms: 15 months postpartum Maternal depressive symptoms were measured at 15 months postpartum using the modified Hamilton Rating Scale for Depression (HRSD; Miller, Bishop, Norman, & Maddever, 1985). The HRSD is a 17-item clinician-rated interview assessing current severity of depressive symptoms. Possible scores range from 0 to 55. The HRSD was administered by trained doctoral level clinicians. 2.6. Maternal sensitivity: 15 months postpartum Following the series of 8 home visits that included observations of mother and infant behavior at 15 months postpartum to assess infant temperament, the research assistant who conducted the home visits with the family completed the Maternal Behavior Q-Sort (Pederson & Moran, 1995). This Q-sort procedure measures maternal sensitivity by comparing a sort of the mother's behavior with a 5

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criterion sort of the behavior of a prototypically sensitive mother using 90 items that reflect maternal sensitivity as described by Ainsworth et al. (1978). Research assistants were trained to reliability criterion of .80 or above (q-correlation with experienced rater). To establish reliability the research assistant observed the series of 8 home visits with the experienced rater and then completed the Q-Sort procedure. Research assistants engaged in refresher trainings throughout the study to minimize rater drift. The research assistant who conducted the home visits with the family at 15 months completed the Q-sort based on their knowledge and experience with the family, and intentionally did not have access to the videos while completing the Q-sort to minimize rater bias between the temperament observation and Q-sort scoring. Lower scores indicate less sensitive maternal behavior. Possible scores range from -1 to 1. In this sample, Q-sort sensitivity scores are highly correlated (r = .65, p < .001) with sensitivity ratings from the Biringen, Robinson, and Emde (1988) Emotional Availability Scales, which is based on Ainsworth et al.’s (1978) work. We focus on Q-sort sensitivity scores rather than sensitivity ratings from the Emotional Availability Scales, because sensitivity ratings from the Emotional Availability Scales in this study were derived from the videotapes of the temperament observations described above, and we wished to minimize inflation of the association of temperament and maternal sensitivity due to shared methodology. 2.7. Family functioning: 15 months postpartum Family functioning was assessed from a videotaped observation of a family meal at 15 months postpartum. We chose to assess family functioning in the context of a mealtime interaction in an effort to capture naturally occurring interactions between members of the family system during everyday events. Each family was asked to select a convenient time when all family members would be available and eating together, and an unobtrusive camera was arranged by the research assistant so all family members were visible for the observation. The research assistant then instructed the family to turn the camera on when they were ready to eat and left the home for the duration of the meal. Following the meal but on that same evening, the research assistant returned to the home to pick up the camera. At the time of the camera retrieval, the majority of families (86%) reported that the meal was either pretty typical or very typical, with only 14% who reported the meal as somewhat typical or not at all typical. Videotapes of the family meal were coded using the Mealtime Interaction Coding System (MICS; Dickstein, Hayden, Schiller, Seifer, & San Antonio, 1994) to assess family functioning. The MICS was closely adapted from the McMaster Structured Interview of Family Functioning Clinical Rating Scale (Bishop, Epstein, Keitner, Miller, & Zlotnick, 1987; Epstein, Baldwin, & Bishop, 1982), with adjustments for the unstructured and naturalistic observation. Raters coded 6 specific domains of family functioning (task accomplishment, affect management, interpersonal involvement, behavioral control, communication, and roles), and also rated Overall Family Functioning which was a single rating that was an integration of the 6 domains, on a 7-point scale with higher scores reflecting higher quality family functioning. The Overall Family Functioning rating was used for data analysis. High levels of overall family functioning represent highly appropriate and effective behaviors and affect in each of the six domains using the McMaster model criteria. Possible scores range from 1-7. Rater reliability was .80 or above (intraclass correlation) and was established based on four reliability sets of 10 videotapes in each set that were double coded by the research assistant and the lead rater (a total of 40 videotapes). 2.8. Data analysis SPSS 24 was used to examine descriptive statistics and correlations between the substantive variables of interest and to examine potential covariates (family SES, maternal age, infant sex, and marital status). Three variables (variability in infant sleep, mothers self-reported depressive symptoms, and maternal sensitivity) were Winsorized to 3 standard deviations prior to data analysis to adjust for statistical outliers. There were two outliers for variability in infant sleep, one outlier for self-reported depressive symptoms, and five outliers for maternal sensitivity. Multiple regression in Mplus 6.11 (Muthén & Muthén, 1998-2014Muthén & Muthén, 19982014), was used to test main and interactive effects of infant temperamental difficulty and infant sleep on maternal depressive symptoms, sensitivity, and family functioning. Separate models were run testing infant sleep efficiency and variability in infant sleep as predictors. All variables in each multiple regression model were entered simultaneously. Covariates identified in correlation analyses (described below in Section 3.1) were included in all regression models. Significant interaction terms were probed using procedures outlined by Aiken and West (1991), and simple slopes were calculated at low (< 1 SD) and high (> 1 SD) levels of the moderator variable. Full information maximum likelihood procedures were used to account for missing data to preserve the sample size of 131 families. Less than 4% of data was missing overall, and Little’s Missing Completely at Random test (Little, 1988) demonstrated that these data were missing completely at random. 3. Results 3.1. Preliminary analyses Descriptive statistics and correlations among the variables of interest are displayed in Table 1. As illustrated in Table 1, family SES was positively associated with mothers’ depressive symptoms at 15 months, and negatively associated with maternal sensitivity and family functioning. Maternal age was positively associated with infant sleep efficiency, maternal sensitivity, and family functioning, and negatively associated with variability in infant sleep. Family functioning was lower among families with boys. Infant sleep efficiency, maternal sensitivity, and family functioning were higher among mothers who were married. Therefore, family SES, maternal age, infant sex, and marital status were included as covariates in hypothesis testing. 6

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Table 1 Descriptive Statistics and Correlations among Substantive Variables of Interest.

1. Infant Temperament 2. Infant Sleep Efficiency 3. Variability in Infant Sleep 4. Depressive Symptoms: 5-12 Months 5. Depressive Symptoms: 15 Months 6. Maternal Sensitivity 7. Family Functioning 8. Family Socioeconomic Status 9. Maternal Age 10. Infant Sex (% female) 11. Maternal Marital Status (% married) Mean/n SD/% Min Max

1

2

3

4

5

6

7

8

9

10

11

– .11 .04 .16 .15 −.05 −.03 −.12 .08 .04 .10 68.24 5.32 57.54 80.33

– −.66** −.06 −.17 −.03 .19* −.15 .21** .10 .23** .94 .03 .86 1.00

– .11 .26** .02 −.18* .11 −.18* −.02 −.09 .04 .02 .00 1.40

– −.57** −.53** −.30** .15 −.10 −.10 −.17 1.93 1.29 1.00 5.63

– −.30* −.37** .20* −.17 −.05 −.05 5.72 6.57 .00 30.00

– .46** −.43** .35** .11 .49** .58 .38 −.79 .88

– −.29** .37** .22* .28** 4.81 1.11 1.00 7.00

– −.48** −.13 −.52** 2.14 .89 1.00 5.00

– .07 .45** 29.42 5.41 17.73 45.89

– .15 63 48% 1 2

– 104 79% 0 1

Note: N = 131. t p < .10. * p < .05. ** p < .01. Correlation coefficients are Pearson correlations.

3.2. Substantive analyses 3.2.1. Maternal depressive symptoms Multiple regression models examining predictors of maternal depressive symptoms between 5 and 12 months and maternal depressive symptoms at 15 months are displayed in Table 2. As illustrated in the Infant Sleep Efficiency Models in Table 2, the interaction of infant temperamental difficulty and infant sleep efficiency was not associated with maternal depressive symptoms between 5 and 12 months or maternal depressive symptoms at 15 months. In contrast, and as illustrated in the Infant Sleep Variability Models in Table 2, the interaction of infant temperamental difficulty and variability in infant sleep efficiency was significantly associated with maternal depressive symptoms between 5 and 12 months and maternal depressive symptoms at 15 months. As illustrated in Fig. 1, simple slopes demonstrated that infant temperamental difficulty was positively associated with maternal depressive symptoms between 5 and 12 months when variability in infant sleep efficiency was high (B = .10, SE = .04, p = .004) but not when variability in infant sleep efficiency was low (B = -.01, SE = .03, p = .742). Likewise, and as illustrated in Fig. 2, infant temperamental difficulty was positively associated with maternal depressive symptoms at 15 months when variability in infant sleep efficiency was high (B = .50, SE = .18, p = .006) but not when variability in infant sleep efficiency was low (B = -.09, SE = .17, p = .586). The interaction of infant temperamental difficulty and infant sleep variability remained a significant predictor of maternal depressive symptoms between 5 and 12 months and maternal depressive symptoms at 15 months when infant sleep efficiency was included in the models as a covariate (B = 2.37, SE = 1.14, p = .037 and B = 12.43, SE = 5.67, p = .028, respectively). Table 2 Regression Models Predicting Maternal Depressive Symptoms. Sleep Measure

Sleep Efficiency Model Socioeconomic Status Maternal Age Marital Status Infant Sex Infant Temperamental Difficulty Infant Sleep Efficiency Infant Temperament X Sleep Efficiency R2 Sleep Variability Model Socioeconomic Status Maternal Age Marital Status Infant Sex Infant Temperamental Difficulty Infant Sleep Variability Infant Temperament X Sleep Variability R2

Depressive Symptoms: PSR 5-12 Months B(SE)

Depressive Symptoms: Hamilton 15 Months B(SE)

.12 (.16) .00 (.03) −.43 (.35) −.20 (.23) .04t (.02) −.21 (4.03) −.10 (.75) .06

1.38t (.78) −.17 (.13) 1.88 (1.77) −.21 (1.19) .20t (.11) −37.04t (21.08) −5.94 (3.72) .17

.04 (.16) .00 (.02) −.43 (.34) −.25 (.23) .05* (.02) 1.25 (5.23) 2.39* (1.14) .10

1.01 (.79) −.14 (.12) 1.46 (1.69) −.32 (1.16) .21t (.11) 59.38* (27.33) 12.35* (5.68) .18

Note: N = 131. t p < .10. * p < .05. ** p < .01. B = beta, SE = standard error. 7

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Fig. 1. Variability in Infant Sleep Efficiency Moderates the Association of Infant Temperamental Difficulty and PSR Maternal Depressive Symptom Severity at 5–12 Months. Note: * p < .05.

Fig. 2. Variability in Infant Sleep Efficiency Moderates the Association of Infant Temperamental Difficulty and Hamilton Rating of Maternal Depressive Symptom Severity at 15 Months. Note: * p < .05.

3.2.2. Maternal sensitivity and family functioning Multiple regression models examining predictors of maternal sensitivity at 15 months and family functioning at 15 months are displayed in Table 3. As illustrated in the Infant Sleep Efficiency Models in Table 3, the interaction of infant temperamental difficulty and infant sleep efficiency was a trend level (p = .073) predictor of maternal sensitivity at 15 months. As illustrated in Fig. 3, infant temperamental difficulty was negatively associated with maternal sensitivity at 15 months when infant sleep efficiency was low (B = -.01, SE = .01, p = .021) but not when infant sleep efficiency was high (B = .01, SE = .01, p = .659). The interaction of infant temperamental difficulty and infant sleep efficiency was not a significant predictor of family functioning at 15 months. Turning to variability in infant sleep efficiency, and as illustrated in the Infant Sleep Variability Models in Table 3, the interaction of infant temperamental difficulty and variability in infant sleep efficiency was a significant predictor of maternal sensitivity, and a trend level (p = .070) predictor of family functioning. As illustrated in Fig. 4, simple slopes demonstrated that infant temperamental difficulty was negatively associated with maternal sensitivity when infant sleep variability was high (B = -.02, SE = .01, p = .001) but not when infant sleep variability was low (B = .01, SE = .01, p = .397). Likewise, and as illustrated in Fig. 5, simple slopes demonstrated that infant temperamental difficulty was negatively associated with family functioning when infant sleep variability was high (B = -.06, SE = .03, p = .032) but not when infant sleep variability was low (B = .01, SE = .03, p = .563). The interaction of infant temperamental difficulty and infant sleep variability remained a significant predictor of maternal sensitivity and a trend level predictor of family functioning when infant sleep efficiency was included in the models as a covariate (B = -.60, SE = .22, p = .006 and B = -1.64, SE = .90, p = .069, respectively). 4. Discussion Infant temperament and infant sleep have long been recognized as individual child characteristics that have the potential to shape parental wellbeing and family relations in the postpartum period (Belsky, 1984; Cowan & Cowan, 2000; Crouter & Booth, 2003; 8

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Table 3 Regression Models Predicting Maternal Sensitivity and Family Functioning. Sleep Measure

Sleep Efficiency Model Socioeconomic Status Maternal Age Marital Status Infant Sex Infant Temperamental Difficulty Infant Sleep Efficiency Infant Temperament X Sleep Efficiency R2 Sleep Variability Model Socioeconomic Status Maternal Age Marital Status Infant Sex Infant Temperamental Difficulty Infant Sleep Variability Infant Temperament X Sleep Variability R2

Maternal Sensitivity: 15 Months B(SE)

Family Functioning: 15 Months B(SE)

−.07 (.03) .01 (.01) .28** (.07) .02 (.05) −.01 (.00) −1.67* (.77) .24t (.14) .27

−.12 (.12) .06** (.02) .22 (.27) .39* (.18) −.02 (.02) 3.09 (3.11) .73 (.55) .19

−.05 (.03) .01t (.01) .25** (.07) .02 (.05) −.01* (.00) 1.55 (.99) −.61** (.22) .27

−.07 (.13) .06** (.02) .24 (.27) .42* (.18) -.03 (.02) −4.11 (3.95) −1.63t (.90) .20

Note: N = 131. t p < .10. * p < .05. ** p < .01. B = beta, SE = standard error.

Fig. 3. Infant Sleep Efficiency Moderates the Association of Infant Temperamental Difficulty and Maternal Sensitivity. Note: * p < .05.

Fig. 4. Variability in Infant Sleep Efficiency Moderates the Association of Infant Temperamental Difficulty and Maternal Sensitivity. Note: * p < .05.

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Fig. 5. Variability in Infant Sleep Efficiency Moderates the Association of Infant Temperamental Difficulty and Family Functioning. Note: * p < .05.

Sameroff, 2009). Yet associations of infant temperament and infant sleep with maternal and family wellbeing are not consistently observed, and these links are often dependent on other risk factors (Crockenberg & Leerkes, 2003a). Surprisingly, no prior work has examined the joint contributions of infant temperament and infant sleep on maternal depressive symptoms, maternal sensitivity, and family functioning. We drew upon observational and objective measures of infant temperament and infant sleep, clinical ratings of maternal depressive symptoms, and observational assessments of maternal sensitivity and family functioning to examine if associations of infant temperament and maternal and family wellbeing are moderated by infant sleep. Results suggest that associations among infant temperamental difficulty and maternal depressive symptoms, maternal sensitivity, and family functioning are strongest in the context of infant sleep difficulty. However, these effects were most consistently observed when considering variability in infant sleep, as opposed to average infant sleep efficiency, across the days of assessment. Collectively, this work underscores the importance of infant sleep for maternal and family health. Infant temperamental difficulty was associated with maternal depressive symptoms, maternal sensitivity, and family functioning when variability in infant sleep efficiency was high, but not when variability in infant sleep efficiency was low. These results suggest that difficult infant temperament may be a risk factor for maternal and family wellbeing only when infants are inconsistent in their sleeping patterns. A more difficult infant temperament, coupled with inconsistent infant sleep, may prevent mothers and families from developing routines, undermine maternal parenting efficacy, and contribute to family conflict. In turn, these risks may contribute to maternal depressive symptoms, insensitive parental behavior, and a dysfunctional family unit. A more consistent infant sleep pattern buffered mothers from the effects of difficult infant temperament, perhaps because these mothers were able to develop expectations and routines relating to infant sleep. Surprisingly, with the exception of a trend level effect on maternal sensitivity, average infant sleep efficiency did not moderate the effect of infant temperamental difficulty on maternal and family wellbeing. Furthermore, variability in infant sleep remained a significant moderator of the effect of infant temperament on all maternal and family outcomes when average infant sleep efficiency was included in the analytic models as a covariate. Interestingly, infant sleep efficiency and variability in infant sleep were highly correlated (r = -.66) in this sample. This suggests that although they are associated with each other, inconsistent infant sleep, rather than consistently difficult sleep, is an indicator of risk. Mothers whose infants are consistently difficult sleepers may have developed routines to mitigate the effects of sleep problems. For example, these mothers may rely on their partner more to assist with night wakings or they may respond less to their infant after bedtime because they have grown accustomed to infant irritability in the night. Mothers whose infants are inconsistent sleepers may not have had the opportunity to develop consistent routines, and they may be awoken more during the night as they have not habituated to infant night irritability. This may have contributed to greater maternal fatigue and subsequently depressive symptoms, insensitive parenting, and family dysfunction (Giallo et al., 2011). An alternate explanation is that maternal depressive symptoms around the time of the sleep and temperament assessments contributed to maternal sensitivity. Indeed, maternal depressive symptoms at both assessment periods were negatively associated with maternal sensitivity and family functioning. When examining this alternate explanation, we found a significant indirect effect of the temperament-sleep interaction on sensitivity through 5–12 month depressive symptoms (B = -.22, SE = .11, p = .048). A similar effect was observed in the prediction of depressive symptoms at 15 months. There was a significant indirect effect of the temperament-sleep interaction on 15-month depressive symptoms through 5–12 month depressive symptoms (B = 6.11, SE = 3.06, p = .046). Future research using repeated assessments over time would add to our understanding of primary mechanisms underlying these effects, as would studies with experimental manipulations (such as depression treatment during the first months of life). Although we observed significant interactions of infant temperamental difficulty and infant sleep variability in association with maternal and family outcomes, this area of inquiry is highly complex due to the interconnectedness of maternal and infant characteristics. For example, environmental factors not considered in the current analysis including maternal sleep and fatigue, and maternal and infant sleep hygiene, may underlie associations of infant sleep and maternal behavior and wellbeing. Shared genetic factors, gene-environment interactions, and prenatal programming effects further contribute to the complexity of these associations. For example, prior research has demonstrated that maternal depression in pregnancy prenatally programs infant temperament (Davis 10

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et al., 2007), and associations of infant sleep and infant temperament are moderated by 5-HTTLPR genotype (Bouvette-Turcot et al. (2015). Future research should draw upon genetically informed designs to disentangle associations among infant temperament, infant sleep, and maternal and family characteristics while accounting for gene-environment correlations, gene-environment interactions, and prenatal programming effects. Our focus on observed infant temperament and objectively measured infant sleep is a strength given that maternal reports of infant behavior are often biased and may inflate associations among infant characteristics, and indicators of maternal and family wellbeing (Sadeh et al., 1991; Seifer et al., 2004). This issue may be especially critical when examining interactive effects of temperament and sleep as mothers who rate their infants as more temperamentally difficult may rate their infants as more difficult sleepers, but these associations may not hold when utilizing observational designs. That observed infant temperament was not significantly associated with objectively measured infant sleep efficiency or variability in infant sleep (Table 1) supports this view. Furthermore, maternal reports of infant temperament and sleep may be more closely related to indicators of maternal and family wellbeing, and the interactive effects observed in the current study may be less likely to be observed than main effects when maternal reports are utilized. Our utilization of clinical ratings of maternal depressive symptoms, as well as independent observer ratings of maternal sensitivity and family functioning, further addresses any concerns related to parent reporter biases. Despite these strengths, there are limitations of our study design. Our sample is relatively homogenous and the majority of families were middle to upper socioeconomic status with mothers who were predominantly white. Future work should examine interactive effects of temperament and sleep in more diverse and low-income samples. Furthermore, it is well established that maternal and family characteristics contribute to infant temperament and sleep. Our focus on infant characteristics that contribute to maternal and family wellbeing addresses a critical gap in knowledge, yet future research should bridge these two lines of inquiry to examine bidirectional effects of infant behavior and maternal and family wellbeing over time. We did not utilize repeated assessments of infant characteristics, maternal characteristics, and the family context over time, therefore interpretations regarding the direction of observed effects should be interpreted with caution. Longitudinal designs are a critical next step for disentangling these complex relationships and understanding factors that contribute to change in maternal and family characteristics. Additionally, the current study focused on actigraph assessment of infant sleep and did not consider maternal reports of infant sleep. Future research should consider both actigraphy and maternal reports to determine if the pattern of results is consistent using both methods. Likewise, future research should examine the role of maternal sleep when examining associations among infant temperament, infant sleep, and maternal parenting behavior and wellbeing. Finally, the interaction effects observed were small to moderate in magnitude, therefore future research is needed to replicate these results with larger and more diverse samples of mother-infant dyads. 4.1. Conclusion The current study demonstrated interactive effects of infant temperamental difficulty and infant sleep variability on maternal depressive symptoms, maternal sensitivity, and family functioning. A difficult infant temperament was associated with maternal depressive symptoms, less sensitive parenting, and greater family dysfunction only when infants were inconsistent sleepers. The observed pattern of moderation effects, rather than main effects, supports the perspective that difficult infant temperament undermines maternal wellbeing and parenting behavior only in the context of other risk factors (Crockenberg & Leerkes, 2003a). To our knowledge, the current study is the first to demonstrate variability in infant sleep as a moderating risk factor in these associations. Taken together, these results suggest that interventions to support consistency in infant sleep may be advantageous for not only the infant, but also for maternal and family wellbeing. Encouraging parents to develop consistent routines at bedtime and throughout the night may be particularly advantageous. Furthermore, pediatricians and other professionals who support families with young children may consider probing parents about their own wellbeing when difficulties with infant sleep are disclosed. Taken together, this work builds upon accumulating knowledge of the conditions under which child characteristics contribute to maternal and family wellbeing. Acknowledgements This research was supported by a grant from the National Institute of Mental Health, Grant # R01-MH51301, R. Seifer Principal Investigator. We thank the many research assistants who contributed to this project, including Maryann Lynch and Michaela Hermann. We also thank Women & Infant’s Hospital and Gail Steffy for assisting in recruitment of study participants. References Aiken, L., & West, S. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage. Ainsworth, M. 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