Patterns of Attachment among Preterm Infants of Varying Biological Risk

Patterns of Attachment among Preterm Infants of Varying Biological Risk ,JAMES W. PLUNKETT, PH.D., SAMUEL .1. MEISELS, ED.D., GILBERT S. STIEFEL, PII.D., PATRICIA L. PASICK, PH.D., AND DIETRICH W. ROLOFF, M.D. The attachment relationships of ;l;l high-risk premature infants, all with moderate to severe respiratory illness and hospitalizations of more than 1 month at birth, are compared to the attachment patterns of :Z:l healthy, premature infants who were initially hospitalized for less than 1 month. Infants with respiratory illness and moderate to lengthy hospitalizations displayed a significantly different pattern of attachment that was more anxiousresistant (C) (:1f1'!(, vs. 9'};, C relationships) than that of infants in the healthy, premature group. Moreover, the pattern of attachments of the healthy preterm group was statistically indistinguishable from the attachment relationships reported by Ainsworth for her normative Baltimore study. Results are consistent with the hypothesis that high-risk preterm birth uniquely and specifically shapes the quality of the caregiving relationship into the second year of life. Journal of the American Academy of Child Psychiatry, ~fj, f1:794-800, 198f1

synchronous interactions between mothers and their preterm infants in the early months of life potentially set the stage for subsequent transactions that can lead to unsatisfying, inconsistent, and unpredictable parent-child interactions (Goldberg, 1977). Despite these findings, relationships between preterm infants and their caregivers in the second year of life have not received extensive attention. Furthermore, research has failed to demonstrate the persistence of interactional effects observed in the first year. Specifically, studies of attachment relationships, as assesed within the Ainsworth Strange Situation (Ainsworth and Wittig, 1969), have shown no differences between groups of preterm and full-term infants and their primary caregivers (Brown and Bakeman, 1980; Field et aI., 1981; Frodi, 1983; Goldberg et aI., 1986, Rode et aI., 1981). Attachment refers to a behavioral system, with roots in early infancy, that represents an enduring affective tie between infant and caregiver (Ainsworth et aI., 1978; Bowlby, 1969; Sroufe, 1977, 1979; Sroufe and Waters, 1977). Researchers who did not find attachment differences between preterm and full-term infant-parent dyadsspecifically Frodi, and Brown and Bakeman-conelude that by the second year preterm birth is no longer a significant determinant of the infant's socioemotional development. However, this finding is unexpected, given the documented early interactional history of preterm infants and their caregivers. The present study reexamines this conclusion, investigating the attachment patterns of a group of infants born at high risk. Given the increased survival and improved prognosis of very low birth weight in-

Infants born prematurely are vulnerable to biological, social, and environmental hazards that can potentially affect their subsequent development (Broman et aI., 1975; Kopp, I98;~; Neligan et aI., 1976; Rubin and Balow, 1977; Werner and Smith, 1977). Recent evidence indicates that these infants and their parents are particularly at risk for interactional difficulties in the first year of life (Field, 1980; Stern, 1977; Thoman, 1980). Preterm infants are often less responsive, harder to soothe, and affectively less positive than full-term infants (Bakeman and Brown, 1980; DiVitto and Goldberg, 1979; Field, 1977). Mothers of preterm infants appear to work harder to engage their infants, are more active and controlling, play fewer games, and receive fewer gratifications from their babies (Brachfeld et aI., 1980; Crnic et aI., 1983; Field, 198;~). Less H,'('(,ll'nJ -lunc S, 19H5; accepted Sept, '/, 1111'S. Dr. J'IUIII!l'It I" Assistant J'mf,'""ur, Dcpart mcnt uf Psvchiatrv and Assistant Research Scientist, Center fur Hunian (lmwlh 1I11d J),."l'!upmcnt, Uniucrsitv uf Michiuun. Dr. Mcisrl« I., J'mfe""ur, Schuul uf Educatiun 1I11d He"earch Scientist, Center fur Human tlroioth 1I11d l letwlcrprncnt, Drs. Stl,,/<'i and Pasick during till' time o] this study «'1'''' Research Assistants, Department uf Educution and J'syclwluM.v, l lnircrsitv uf Michiuan. /Jr. Huluff Is J'mfessur a] Pediatrics 1I11d Director o] the Holden Nconatal lntensiiv Care Unit, Unicersitv uf Michigan Medical Schuul. Hcprints 1Il1ly he requested [rom Dr. Plunkott. Children's Psvchiat ric Hospital. l lcpnrt mcnt uf Psvchiatrv, Unircrsitv uf Michiean, AIIII Arbor, MI·/H/ti9 This research /I'll" supporu-d hy a faculty research auard [rom the Rackhum Graduate Sclwul uf the I 'nircrsit v o] Michigan. The authors uould lil«: tu thank 111f' parcnts 1I11d children uho participated III this study. They are also urat cfu! tu L Alall Srou]« and S. WaY/le Duncun fur coding the attuch mcnt tapes. and L Alall Srou]« fur his adric« thruuuhout this studv, and Dai-id U. Cm"" fur his i-alunbl« statistical

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794

PATTERNS OF ATTACHMENT AMONG PRETERM INFANTS

fants born wit h significant neonatal and post natal complications (Hack et aI., 1979), systematic study of the early relat ionsips of such infants with their parents is essent ial before conclusions about their development are drawn. Previous preterm attachment studies have been dominated by relatively healthy infants. For example, Frodi's (19l't{) :W preterm infants had a mean birth weight of 1990 grams, and an average hospitalization of24 days (range = 7-74 days). Brown and Bakeman's (1980) sample of 26 premature babies had a mean birth weight of 1627 grams, and a mean hospitalization of 26.6 days (S.D. = 2f).6). (Brown and Bakeman (1980) did not use the standard scoring procedures for the Strange Situation. They arrived at classifications by utilizing transcripts obtained from Datarnyte recordings, rather than videotapes of the entire procedure. Thus, their results are difficult to evaluate, and cannot be generalized.) The mean hospitalization of Rode et al.ts (1981) sample was also less than 1 month (26.7 days). (Rode et al.'s (1981) study was somewhat different from the other studies discussed in this paper: it focused on the impact of initial separation, rather than the impact of preterm birth per se. Although all of their 24 infants were hospitalized as neonates, 4 were not prernature.) Field et al.ls (1981) sample consisted of 46 premature infants, all of whom had respiratory distress syndrome (RDS). However, the sample was not very sick, very small, or hospitalized very long (mean birth weight = 1600 grams; mean gestational age = ;{2 weeks; mean length of hospitalization = ;{2 days). Moreover, the absence of reported differences in this study is hard to assess because the conclusion of no differences in quality of attachment contrasts full-term to preterrn and post-term infants. By including post-term subjects in the analyses, the distribution of the attachment patterns among the preterrn sample cannot be determined. Only the research of Goldberg et al. (1986) provides an exception to these studies of relatively low-risk infants. They studied 17 twins and 2f) singletons with birth weights <1f)00 grams and average hospitalizations >60 days. At 1 year of age, 7f)% of their subjects were securely attached and-unexpectedly-severity of illness was associated with greater security. In short, wit h the exception of the Goldberg et al. (1986) report, none of these studies specifically investigated the effects of severe neonatal or postnatal risk conditions or mean hospitalizations substantially greater than 1 month. Since subgroups of high-risk premature infants (e.g., those with very low birth weights, or infants with chronic lung disease) have been found to demonstrate less optimal cognitive development than groups of healthy preterrns (Marke-

79f)

stad and Fitzhardinge, 1981; Meisels et aI., 1986; Rothberg et aI., 1981; Siegel, 1982), it is possible that differences in attachment between preterm and fullterm infants might emerge if samples are selected differently. The present study compares the quality of attachment relationships of two groups of premature infants that were selected to differ by degree of postnatal biological risk and potential impact on the caregiving environment. The groups consist of a respiratory illness group that includes preterm infants with moderate to severe lung disease and hospitalizations of greater than 1 month; and a healthy group of premature infants with no respiratory illness and with hospitalizations of less than 1 month. Thus, the groups differ both by degree of respiratory disease and length of initial hospitalization. Two hypotheses are tested in this study. First, premature infants with respiratory illness and hospitalizations of more than 1 month at birth will display different and less optimal patterns of attachment with their primary caregivers in the second year of life than healthy premature infants who are hospitalized for less than 1 month. Second, healthy preterm infants with initial hospitalizations of less than 1 month at birth will demonstrate patterns of attachment in their second year that are similar to the normative attachment relationships that have been reported for healthy, full-term infants by Ainsworth and her colleagues (1978). Additionally, a research question is posed: to what extent are differences in the quality of attachment between respiratory ill and healthy groups of preterrns reducible to between-group differences in birth weight or gestational age, or length of hospitalization?

Method Subjects This sample was drawn from a study population of 62 premature infants. All subjects weighed less than 2f)01 grams at birth, and gestational age as assessed by Ballard score (Ballard et aI., 1979) was less than ;n weeks. The subjects were identified from case records of consecutive admissions to the University of Michigan Hospitals from September 1980 to -July 1982. After subject selection, families were contacted by letter and phone call. Of the 82 families who were contacted, 6f) agreed to participate though 3 were later dropped when it was determined that 2 subjects did not satisfy the selection criteria and 1 had not been evaluated according to the established study protocol. Furthermore, as will be explained below, 6 infants with respiratory illness who were originally included in the study could not be classified in the Strange

79G

PLUNKETI ET AI. .

Situation, and thus are not included in any of the descriptive data presented bel ow. Informed consent was obtained, and all families receiv ed reimbursement for t he cost of t rave I and expenses. Infant s were assigned to o ne of tw o crite rion groups: a respiratory illness group o r a healthy group. The infant s in the respiratory illn es s group had moderate to sever e lung disease and an init ial hospitalization of more than I month. Infant s in the healthy group wer e free of resp iratory illness a nd wer e hospitalized for less t han I month. Th e mean birt h weights and gestational ages of the two groups were significantly different. The mean birth weight of the respiratory illn ess group (N = :~:3) was 1419.G grams (S.D. = 4:W.9), and that of the healthy group (N = :2:~) was :21:~ R .6 grams (S.D. = 279.4), f (I , ;>4 ) = 7.0R, p < 0.0001. The mean gestational age of the respirat ory illness group was :W .7 week s (S .D . = :2.!i), compared with th e healthy group 's mean of :\:t 9 week s (S .D . = 1.9) , f (I , G4 ) = :1.:26, P < 0.0001. The crite rio n groups wer e selected to ha ve non -overlapping lengt hs of hosp ital ization . The respiratory illness group had a mean hospitalization of no.;> days (S .D . = :27 .:2, range = :2H- I:2 I ), and the healthy group mean ho spitalization was 10.:2 day s (S .D. = 7.4, range = :2- :26 ). Parent s wer e encoura ged to vis it th e ir infant s at this medical ce nte r as often as pos s ible and most parents made ext ensive use of this pri vilege . To better assess the imp act of respiratory illn ess and its sequelae, infants were excluded from the st udy if t hey had central nervous syst em , neuromuscular , or sensory disorders; hydrocephalus; int ravent ricular hemorrhage> grade :2; ret rolental fibroplasia; severe congenital or metabolic disorders; severe hyperbilirubinemia; or int rauterine growt h failure. Uncont rolled variation in the caregiving en vir onment was reduced by excluding from the study mothers who had been addict ed to drugs or alcohol during pregnancy, those who had seve re mental di sorder, or those wh o were less than 17 yea rs of age at th e t ime of the child's birt h. Furt her more, infants who had not lived with their ca regive rs continuously si nce in it ia l discharge were excluded . Bal an ced representati on of sex of child, parity, fam ily con fi gura t ion , socioecon omi c st atus (SES ), and maternal ed ucat io n was achieved ac ros s groups. There were no sign ific a nt differences between the two risk groups for a ny of these fact ors. In this sa mp le, 41 % were from low SES families (classes IV and V of the Hollingshead Four-Factor Index) , !}4 'I"~ of the infants wer e mal e, 6(j% were first born , R4% were from twoparent homes, and all but two child ren were Cauca sian. The mean maternal edu cation was 1:2.:1 years

(S .D . = 1.9 ), and mean mat ernal age was 26.1 years (S . D. = :1.R).

AW' S f ratificat ion

Although part of a longitudinal investigation, this ph ase of the st udy was cr oss-sectional. Subjects were eva luated at one of two time points: 1:2 months (N = :29 ), or 18 months (N = 27 ) time post-hospital discha rge (TPD ). Because of our interest in studying the de velopment of infant- caregiver relationships, TPD was chos en as a time point for asses sme nt rather than chronologica l age corrected or uncorrected for gesta tion al age. In this way, even though the risk groups differed by length of hospitalization, all subjects were pr ovided with comparable opport un it ies to benefit from the experience of a primary caregiving environ ment. Since attachment is related to the history of transactions between caregiver a nd infant, it was conside red advantageous to equal ize the amount of time tha t eac h infant spent at home. The TPD was stratified in order to explore wh ether a longer time at home would be associated with more sec ur e attachment. At 1:2 months , there were 17 resp iratory illness and 1:2 healthy group infants; at 18 months there were 16 respiratory illness and 11 healthy infants. There were no sign ifica nt differences in th e di stributions between the 1:2 - and 18-month age groups within risk group on sex, parity, fam ily configuration , SES, or maternal education.

I)n icedu res Th e sta nda rdized procedure of conducting and cod ing the Ainsworth Strange Situation was employed (Ainsworth and Wittig, 1969; Ainsworth et aI., 1978). Although some episodes were curt a iled due to infant dist ress, none was eliminated . The entire procedure was videotaped. With the exception of two children wh ose primary caregivers were their fathers, all chil dren were seen with their mothers. C lass ifi cat ions of the subjects ' quality of attachment wer e assigned in terms of a nxious-a voida nt (A), secure (8 ), o r anxious-resistant (Cl by a senior investigator (L. A. Sroufe ) who was trained by Ainsworth, and by a coder trained by the sen ior inve stigator. Coding of videotapes took place at the University of Minnesota; code rs were blind to the study's hypotheses and to risk group membership of the infants. Interrater reli a bility , ca lcula ted by dividin g the agreements by the agree ments plu s t he dis agreements, was 0.88 , based on :1:2 vide otapes coded independently by both raters. Disagreements were resolved in co n ference between t he two coders. Fifty-six subjects received attachment classifi ca t ions. One subject wa s not scoreable because he left the room during the seco nd reunion episode of th e Strange Situation procedure. Four subjects could

797

PATTERNS OF ATTACHMENT AMONG PRETERM INFANTS

not be validly coded due to extreme psychomotor immaturity and delays, and one subject was not classified because he demonstrated extremely unusual behavioral patterns. Rat her t han force classification of these subjects, and risk reducing internal consistency and validity, these subjects were dropped from analysis. The () infants who were excluded from analyses did not differ from t he remaining :~:~ respiratory illness infants by birth weight, gestational age, length of hospit.alizat ion, or any of t he demographic variables with the exception of maternal education. The mothers of the () who were dropped had a mean education of 1:~.R years (S.D. = ~.()), compared to 1~.:~ years (S.D. = 1.4) for the respiratory illness infants who were included in the analyses (t (I, :)7) = ~.07, p < O.OG). The remaining :~:~ respiratory illness infants do not differ from the healthy infants on this factor.

Results Before testing the first hypothesis the data were examined for possible age group differences associated with stratification of the sample at I~ or l S months TPD. To detect any main effects or interaction effects of age groups, the screening features of the BMDP4F program (Brown et al., 19RI) were utilized. No significant main effects for age group on attachment were found (x~ (~) = 1.17, p = O.G()). Moreover, there was no interaction of age group by risk group (x~ (2) = :t 7(), p = 0.1 G). Thus, for t he purpose of data analysis it was possible to combine subjects across the 1~- and I S-mont h age groups. The first two columns of Table 1 present the contingency table analysis comparing the attachment classifications of the respiratory illness group to those of the healt hy group. The significant ly different patterns of attachment between these groups provide support for hypothesis I (x' (~) = 8.~8, p < (l.()~). The respiratory illness group has a somewhat smaller proTABLE I

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portion of B, or securely attached infants. However, the pattern of insecure attachments-the A (avoidant), and C (resistant) relationships-is very different. The high proportion of C relationships and the few A relationships among the respiratory illness group contrasts sharply with the greater proportion of A and the smaller proportion of C relationships in the healthy, premature group. The results displayed in Table 1 also provide st rong support for hypothesis 2, that healthy, low-risk premature infants will display attachment patterns similar to those expected among a healthy, full-term normative sample (Tahle 1). A x' goodness of fit test establishes that the distribution of attachment relationships among the healthy preterm infants closely approximates the distribution found among Ainsworth's original sample of lOG healthy, middle-class subjects (Ainsworth et al., 1978) (x' (~) = 0.%, NS). By contrast, when the respiratory illness group is compared to the Ainsworth sample, the difference between the groups is evident (x' (~) = 10.69, p <

o.oi ). Attachment and Perinatal Characteristics A primary aim of t his study was to explore whet her attachment patterns of preterm infant s would differ if sicker and longer-term hospitalized infants than those studied previously were invest igated. It was assumed that selecting subjects according to these criteria of biological and caregiving risk would result in the formation of more homogeneous risk groups than would be possible with such nonspecific criteria as birt h weight or gestational age. Since the respiratory illness group and the healthy group were expected to differ significantly by birth weight and gestational age, the association of risk group with attachment classification was explored to determine if attachment differences could simply be reduced to between-group differences in these perinatal characteristics. Table ~ shows that differences in quality of attachment are not reducible to differences in birth weight or gestational age. Examination of the attachment group means in the one-way ANOYAs in Table ~ indicates TABLE :!

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79R

that infants with a C, or anxious-resistant relationship, have t he lowest birt h weights and shortest gestational ages. Infants with B, or secure relationships, had mean birth weights and gestational ages that fell between the infants with A and C relationships. However, due to extensive variability there are no significant differences among the attachment group means. Thus, even in preterm groups with significantly different perinatal characteristics, birth weight and gestational age alone are not reliable predictors of attachment. As noted earlier, infants in the two study groups were selected to have non-overlapping lengths of hospitalization. Nevertheless, because of within-group variability on this factor, the association of length of hospitalizat ion with attachment was also tested. As with birth weight and gestational age no significant results were observed (F (2,.S;~) = 1.69, NS). In this sample, lengt h of hospitalization alone is not a good predictor of attachment classification. Discussion This study focused on the attachment patterns of preterm infants with significant respiratory problems and prolonged hospitalization. It sought to discover whet her these infants and their caregivers displayed different and less optimal patterns of attachment in the second year of life when compared to healthy preterm infants who experienced brief hospitalizations. The significantly different patterns of attachment that are displayed by t he respiratory illness group confirm that differences in patterns of attachment will emerge when preterm samples are composed principally of high-risk infants. In contrast, as predicted, the attachment patterns of healthy, preterm infants are statistically indistinguishable from those of the healthy full-term sample in Ainsworth et al.ls (197R) original study. With one exception studies of attachment patterns among preterm infants (Brown and Bakeman, 1980; Field et al., 19R1; Frodi, 19R;~; Rode et al., 19R1) either focused on groups of preterrn infants who were primarily at low developmental risk, coded the Strange Situation paradigm according to nonstandard procedures, or selected groups by a single risk criterion. This investigation implemented and coded the Strange Situation according to Ainsworth's original criteria, and studied infants born at high risk. Moreover, this study utilized multiple selection criteria of risk status rather t han such single selection criteria as birth weight, illness, or length of hospitalization. For example, in Field et al.'s (19R1) study premature infants were selected for presence of RDS only; the hospitalizations of these infants varied

widely with an average of slightly more than 1 month. Rode et al. (I 981) focused exclusively on length of hospitalization, and did not select for type of illness or for birth weight. In contrast, the present study predicted that groups of preterm infants selected both by degree of biological illness and by length of separation from the primary caregiving environment would more likely reveal the sequelae of high-risk birth than would more heterogenous groups of premature infants selected by a single risk factor. In the one comparable study of attachment among high-risk preterm infants, the findings of Goldberg et al. (1986) are inconsistent with these results. Their finding of 75% secure (B), 18% anxious-avoidant (A), and 7% anxious-resistant (C) attachment relationships represent a strikingly different distribution than that reported in this study. While methodological factors may account for the differences between the studies, the need for replication is clear. Of particular note in this study is the preponderance of anxious-resistant, or C, relationships in the respiratory illness group. Infants classified as C show a mixture of contact-seeking and contact-resisting behaviors. Babies in C relationships demonstrate an ambivalent affective quality, and their interactions with their caregivers are usually described as unsatisfying, inconsistent, and unpleasant (Belsky et al., 19R4; Egeland and Farber, 1984; Sroufe, 198:~). No other study of preterm infant-caregiver attachment has reported the distribution of A and C attachments seen in this sample. What may account for the high proportion of C relationships? One response to this question focuses on single factors that differentiate the groups. For example, since the criterion risk groups significantly differed by birth weight and gestational age, it is possible that smaller and gestationally younger babies are more prone to the type of irritable behavior displayed by anxious-resistant infants. However, examination of the data show that these characteristics are not reliably associated with attachment classification. Still another factor to consider concerns length of hospitalization. Are babies who are hospitalized longer more likely to demonstrate a specific type of attachment classification? Although there was no statistically reliable association between hospitalization and attachment, a complete test of this relationship would require the formulation of a control group matched with the Respiratory Illness group for length of hospitalization but free of respiratory problems. Since most babies with long hospitalizations but without other major complications have low birth weights, and since the incidence of respiratory problems among infants weighing less than 1500 grams at birth exceeds

PATTERNS OF ATTACHMENT AMONG PRETERM INFANTS

GW:r (Korones, 19H1), such a control group is difficult if not impossible to obtain. From the data available in this study it can be concluded that differences in attachment relationships are not solely reducible to the single neonatal variables of birth weight and gestational age nor to length of hospitalization. Rather, another explanation for the preponderance of C relationships potentially lies with the impact on the infant and caregiver of preterm infant illness combined with prolonged initial hospitalization. Prospective studies of attachment patterns (e.g., Ainsworth et al., 197H; Bell and Ainsworth, 1972; Belsky et al., 19R4; Egeland and Farber, 1984; Main, 19R:~) suggest that the C relationship indicates the presence of an infant who is anxious, hard to soothe, and who gives mixed signals to the caregiver. The anxiousresistant classification also implies the presence of a caregiver who, during the first year of the infant's life, has difficulty being consistent, sensitive, and responsive to infant needs-a mother who is not very effective in her caregiving efforts, and who is emotionally ambivalent about her infant. Such an early transactional history is consistent with studies of preterm infant-caregiver interact ions in t he first year that have identified a relationship among adverse neonatal experiences, the stress of the infant's postnatal illness, and subsequently less synchronous and more difficult mother and child interactive behaviors (Brachfeld et al., 19RO; DiVitto and Goldberg, 1979; Field, 1977; Greene et al., 19R:n. It is likely that vulnerability to the effects of a high-risk early history would markedly increase among such premat ure infants as those who participated in this study: infants who experienced moderate to severe biological risks, and whose initial relationship with their caregivers was marked by lengthy separations and parental anxiety. * The finding of nearly :~6~;) anxious-resistant (C) attachments within the respiratory illness group is, moreover, in complete agreement with predictions from attachment theory in which one would expect chronic illness to create anxiety in caregivers but not necessarily make them unavailable (Sroufe, 1985). When compared to Ainsworth's sample, neither the 61 % B, nor the :~WI;) A relationships found among the healt hy group are markedly different from t hat which • Lamb et al. (1 m'·ll have challenged till' dist inct ion between A and (' classificat ions as arhit rurv and lacking in empirical subst ant int ion. Lamb and his colll'ah'lIPS sllggl'st that till' two catl'goril's can he joined into a singh- anxious, or insecure classificat ion. However. such an approach is inronsist ent wit h data from prospect ive studies that haw identified dist inct ly different relationships in till' first war of life for infants later classified as "A" or "('" (Ainsworth et ;11., 1~17H; Bl'lsky «t aI., 1m,·\; Egpland and Farber. 19H·\). Recent replicat ion of Ainsworth's validation st udy also confirm till' reliahilit y of her original invest igat ion (;rossman et al., 19H:l). Thus, there is precedent and justification for maintaining till' dist mrt ion between A and (' classificat ions.

799

could be expected in a full-term, healthy sample. This finding lends support to the assumption that after the first months of life healthy preterm infants are not generally subject to interactional influences that are qualitatively different from those that affect healthy, full-term infants and their parents. It should be noted that our results show that highrisk preterm infants with respiratory illness are not at risk for developing anxious-avoidant, or A, relationships marked by caregivers who are angry and physically rejecting. Moreover, 55% of the respiratory ill infants are securely attached, demonstrating a resilience to biological risk and a history of positive parentinfant interactions. This study demonstrates that those infants who remain at risk into the second year are at greatest risk for developing relationships that reflect their caregivers' difficulty in overcoming an initial need to disengage emotionally from an infant who may not survive, and who continues to be difficult to care for. In Stern's (1977) words, the parents of these infants may be "unwilling victims of an involuntary inhibition of their caregiving" (p. 29). These conclusions suggest several foci for intervention: the infant, the infant-parent relationship, and the parents' network of social support. In particular, attention should be devoted to helping parents accurately read and respond to their baby's behavioral cues; assisting parents to initiate positive social interactions, games, and responses to their infant's behavior; and helping parents provide a secure base for their babies' exploration, and a comfort in times of stress. Parents should be supported in working through their ambivalence, uncertainty, and guilt concerning the birth of a high-risk infant. Such responses interfere with parents accepting their parental role and making themselves emotionally available to their infants. A formal and informal network of other parents of highrisk preterm infants may serve to buffer the irritability and difficulty of a high-risk infant and may provide emotional support through interpersonal acceptance, sharing experiences with others in similar situations, and demonstrating concern for the family as a whole. The results of this study suggest the likelihood of a continuity in patterns of relationship from the first to the second year of life for infants who experience a high-risk postnatal course. Earlier reports on the failure to find a pattern of socioemotional influence beyond the first year for premature infants should not be taken as definitive. Our results, although not prospective, suggest that in subgroups of high-risk preterm infants there is a significant probability that postnatal medical condition and long-term hospitalization will interfere with the establishment of confi-

ROO

PLUNKETT ET AI..

dent infant-caregiver reciprocity and growth-enhancing mutuality.

References AINSWOHTII. \1. I), S,. I\: \\'1'1"1')(;, B, A II!Hi!IJ, At t arhment and ('xplnrat()f.\' ht:ha\"jtlr of 1IIH,-.\,par-lllds in a strang(' situation In: l h-u-rminant» ,,/ 111/11111 Ikhw'i", II', pd, JU\1. Fo", London:

1\1"1 hur-n

c.

\\',\TEHS, K So WALl .. S, II!!~KI, L'uttcr ns ,,/ udv ,,/111<' Simllg" Sil 11111 ion , l Ii lls dale. ",.1: Lawn'lll'" Erlhalnn A"ocialps, BAKE\IAr", H, So BHOWr", .1, V. II!!KIII, Earlv internet ion: consp qn"IH"'S lor social and nu-nt al dp\plopnlt'nt at t hn'" vr-ars. ('/IiM 11,,/,"'/,," .. ',I :t:\~ ,l,l~ BAI.I.AIW,.J L, "mAK, K, K, So DHI\'EH, M, (I!!~!IJ, A sunplifir«! scon' Ior a:-'St'sslllt'1l1 Ill' ft'talrllallllllritioll of m-wlv horn infants.

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.J. !'I'dwl .. q:):~I;,'" 7~·,1. BELL. S :\1 So AINSWOHTII, !\1. D, S, I I !I';":.' I, l nfunt crying and Illalprnal n'SpOnSl\"'IW", ('hlhl 1),'/''''1'111.. ,1:\:11,;"1 11!IIl, BELSKY, .1" HO\I:"I':, :\1 So TAYl.oH, D, I 1!IK,1 I, Thp Pennsvlv.miu I ntunt and Funulv Ilt,\ploplll,'ni I'roj,'cl; III. The origins 01' indi vidu.rl ditl,'r"lll"'S In iniunt '1ll01 11I'r .u t .uhnn-nt: mutvr nnl and i n lunt con t r ihut ions, ('llIld I ),oITIl'lI/ .. ;,;,:';" IK ';":.'K. BOWI.BY .. I. I I!Hi!IJ, ..1//11";1111<'111 111111 I.""", 1',,/ / r I/lIIChl/I<'1I1. 1'\,'w York: Basil' Books, BHACIIFEI.D. S .. COLIIBEHI;. S, ,,\: SLOMAN ..1. I I!I,>;III, Pan-nt-i nfant inu-rurr ion i n tn'p pla\ al ,>; and I:.' mont hs: ..rl'pcls ofprt-mnt ur it v and inunat ur it v. 111/11111 lsrluu: 1i''/''''/JlTI" :\::.'l'\!1 :HI;l. BHOMAr", S, II" "WIIOI.S, I' I.. So KE:"NEDY, W. A. II!!';";". l'r« scluml Lt]. l'r"III1II1/lIl1d Earlv 1),o1''''''/JlI/''1I1 ('"rn'IIII ..v. Hillsdalv. 1\.,1.. Luwrr-nrr Erihalllll A"ociatps. BHOWN .. 1. Y So BAKE\IA:". H, II!IKIII, H,·lalionships 01' human mot lu-rs wit h t lu-i r intnut » dur iru; till' first vvar 01' life: ,'I'fpcl 01 prr-mat urttv In: Milia/wi l nllurncr. IIl1d Earlv Bcluuior, pd, H, W B,'II So \\'. 1'. Sn",lh"rlllan, :'\ipw Y"rk: Sp('Clrulll. pp. :1',:\ :l';":\. BIW\\'r", :\1. B, ENI;EI.\lo\N. 1... FI(ANE ..1, W" lilLI., :VI. A ... IE:"r" H)('II. H. I. So TllI'OHEK, .J. I). II!!KII, nMI)/' SllIli.,l/m/,,,,'''fll/fIrl' Ikrkpl,'\', (·alil.· t 'ni\,'rsit\, of ('alifornia I'n'". ('HNII', K, A" HAI;OZI:", :\, S" (;f()':ENHEHI;, 1\1. '1'.. HOHINSON, :\ !\1.l~ HASIIA\1. H. B.llqH:~).~(H'i of pn-tprlll and full-tern1 illfant:-; during tlu' lir:-;t .\"l'~lr of IiI',', ('/lIld /J"I..J/JlII , ;,.]: I I !!!I I:.' III, 1)1\'1'1''1'0, B. '" (;Ol.lllWHI;, S. II !!';"! Ii , Tlw !'Il""ts of npwhorn nwdical sl at liS "n "arh pan'nt in fanl Inlt'ract ion, In: Inflllll,' H"m III /(lsl... Hl'illlll"r Illld 1),01 "'''/Jl7/1'III, ('d. '1'.1\1. Fi('ld, A. M. S"sl('k, S, (;oldllt'rg ,,\: II. II, Shlllllan, !\;pw York: Spp('tnlJll, pp, :\11 :\:1:.', EI;EI.Ar"II, Il, '" FAHHEH, K A. 11!IK,II, Infantlllotlwr atlachnwnt hH'tllr:-; rt'lalt.'d to it~ d('\'(·lo!>llH'nt and changp:-; (I\'(.'f tillH'. ('hild I Jl'1'1'//HU" ;);):'";":1;) ---;---; I F If: 1.1I, '1', I I !!';"';" I, EII,,(,t, "I' pari\' "'parati"n, inl('ral'lin' d!'liclts, and ('xpt'ritllt'ntal lllI pn' and post ,krill infants, In: I'rl'i"rrll Hirlh Ilnd l's\c!I"/,,glClll 11"If'!"/iI7/f'nl, ,·d. S.L. Fripdlllan So M, Siglllan. ~"W Y"rk: Acad"lIlie I 'n'ss, pp, :.'!I!! :\1:.', FHOIII, A, I!!!K:\), Attadllll,'nt hpha\'ior and Sfll'ia!iahilil\ with sl rang"rs in prp'llatllrt' and flllllt'rJll infanls, Infllnl M,'nl IIllh •/. ,I: 1:1 :.'~, (;O!.PHEHL, ~. ( 1~'---;"7). Social ('lllllIH.'tt'IH'(' ill illfHI1Cy: a IllfHh·j of pan'nl infant inl,'r,,,,ti"ll. .\ferri//·I'u/I//I'r (/lIllrl., :.':\:](i:1 I,;"~.

I'EI(lWTA, M, ;\llr"III':, K, So ('OHTEH, t '. 11!IKlil, Malprnal h('ha\'ior and at t arhnu-nt in low hirt hweight: twins and sing!('tons. ('1111" /J(",,'lpm., ;,';"::\.1 ,IIi (;HEENE, .1. C .. Fox, 1\, A. '" LEWIS, :VI. I 1!IK:\i, 'I'h« relat ionship het w""n m-unat al charact pflst ics and I h n-v-mont h mut her infant inu-ruct ion in high risk intant s. Child 1),oI""/JlII .. '''):I:.'Kli 1:.'9Ii. (;IWSSMAN, K., (;HOSSMA:", K, E .. SPA:"I;I,FH. (;" Sn:ss. (;. So I 'NI;NEH, I.. 11!!Kc>I, Mat er n.r! se-nsit ivit v and newborns oru-nt alion f('sponsps as n-lat ed to qllalit y' of at t.uhnu-nt in northern (;('rlllan\" M"n"gr, S"" II"", ('hlrl/kl'..Jpm .. ;,()::.':n :.';,Ii, HACK, M" FAr"AHOFF, A. A, '" \IEHKATZ, I. H. 11!1,;"!Ii, 'I'll!' low hi rt hwr-iuht infant evolut ion of a ('hanging uut luok .. Vf'Il' "-'fl~1 .i. :\11 J: I Ili:.' ! Ilili. Kopp, t'. H. 11!!K:\i, Risk lactors in development. In: Infll"".\' iuul 1),01 ''''o/JII/('I1I111 I '''\'l'hO!JIII/IIg\', «d. M, :\1. Hait l. So .1. .1. Campos. :'\i,'\\' York: .Iohn Wilev '" Sons, pp. I 11K I II KK. KOHO:"ES, S. H. II!!KII, ltich-Ri»!.. NI'II'!Jllm l nlants. Ed, :\. SI LOllis: ('. Mosh\,. LAMB, ;\1. 1>:., TIIO\lI'SO:", H, A., CAIWNEH, W. I'., ('IIA1(NO\', I>:. I •. So ESTES. I), I!!)l'\·ll, S('cllrily- of infunt ile au arhmr-nt as as· :-;t>~~t'd in t he ":-;trangt ' sit u.u ion": it s st udv and hiological inu-r pret at ion. Iii-hili' Hruin Sf'l .. ~·I:.'';" 1';"1. MAIN, \1. II!IK:O. Exploration, plav, and cognill\'" [unrt ion nu; no. lalt·d to intunt-mut lu-r .u t arhuu-nt . I nla II I Bchiu, 1),o/'l'i1'7II., Ii: Ili,;" I ';"1. I\1AHKEsTAIl, T. So FITZIIAIWINI;E, 1'. M. 11!IKll, (;rowth and d('· Vt'IOPIlH'llt in «hildn-n n'('ov('ring from hronchnpulmonurv dvsplasi». J I"'fhlll., !IK:;,!!';" Iii I:.'. :\1I-:ISEL,', S .1. I'I.I:-;KETT, .1. \\' .. HOLOFF, I), \\" I'ASII'K, 1'. I.. ,,\: STIEFEL, I; S, II!I,>-;Ii" (;mwth and d"\,'lol"IH'nt 01 pn-tr-r m Inlanh Wit It I\I)S and BI'I), I 'I'{I/(/I I'/ f ''' , ';"';"::\1;, :1;,:.', :'\;ELII;AN, C, A .. KOL\Ir", I., SCOTT, l i. So CAHSIIIE, H. F. 11!)';"til, Born Too S""" or !i"m '1'"" S7IIII// A F"I/,,"'ufl St udv I" S"",'n r"lIr" "f ..Igl' London: W. l lr-inem.uu, M"dical Books. HOllE, S, ('IIANI;, I' .. FISCII, H, So SHOI'H':, L. (I!!KII, At t arhnn-nt pat t erns 01 infants S('paratpd at hirl h, /J"I'l'iI'711 I '''\'ch"J. , I';": IKK I !II. HOTIIBEHI;, A, ll .. :\lAISELS, :\1, .1.. BAI;NATO, S .. \ltHPIIY, .1.. (;IFFOIW, K, :VlcKI:"I.EY, K .. I'ALMEH, E. A. So VA:"NI'('('I. H. ('. II !IKII, ()lItcolll" I"r sllr\i\'ors of nw('hanical \('nl ilat ion wpighing Ipss t han I ,:.'c,1) grn al hi rt h .•/. I 'I'd ill I , !!K:IIHi': I I I. HI'BIN, H. A, '" HALOW, H, I I !I';"';" I, I'('rinalal intllu'IH'Ps on Ihp In'ha\lor and I('arning prohl"llls of childr('n, In: ..ldl'IInl"'" ill ('llIl/crIl ('IIIIr! I',\('holu~\, Vol. I, ('d. B. B. Lak('\, '" A. E. Kazdin. "t·\\· York: I'!,'nlllll. SIEI;EI.. I., II'IK:.'I, H"prudlleti\'p, pninatal. and ('n\,ironnwnlalla('· tors as prt·dil'tnrs of t lH' cllg-nit iv(' and langllage dt'v('lopnll'nt of prptprlll and 11I1I·I,'rlll infants. ('llIld !JI'I'l'i/JIIl .. ;,:UHi:l !!';":\. Slwt'FE, L. A, I I !I';"';" I, \,'ari'H'ss of slrangl'rs and th,' stlldy' of infanl d,·\'ploJlIll,'nt ('III'IrIIJ,'/'l'i/iTII" ,IK:,;":11 ';",lIi. - - 11!!,;"!Ii, Soc,opnH,lional d"\,p!opnwn!. In: IIl1ndlw,,1.- of IlIfllnl I),'/'l'i"fi"ll'nl, pd, .I,ll, ()sofsk\'. "pw York: .John Wil,'\' '" Sons, pp,lli:.' 'd'i, - ( I ~JS:~), IllfaIltl':--;chu()l: tlH' fouts of rnaiadaptatioll and ('onllwtl·Jl('l'. In: Tht' Alllln"",,11I S\IIl/ul,'w "n ('hilr! l'sYl'ho/"g.\', \'01. Ili, pd. 1\1. I'prl· rnlltlpr. Ilillsdal,·. N..1,: Lawn'nl'(' Erihalllll Associal'·s. ---II!IK;'l, Attachllwnt c1assificalion from til!' p('rsp('cli\,(' of in· fant ·car('gi\,pr r('lat ionships and inlant Iprn!,,·ranwnl. ('hilr! /JI'l'f'I/JlII" ',Ii: I I ,I. - - '" \\'ATEHS, E. 11!1';"!lI. Attaehnll'nl as an organizational con· strue!. (,hilr! 1),'/'l'ip7ll .. 1,>;:1 IK,I II!I!J. STEHN, I). I I!I';"';" I, '1'1", Flr,,1 /ll'illll'm"hil'.' Infanl and Mo/l"'r ('alll' hridW" 1\1ass.: lIar\'ard t'ni\,prsity' I'r('ss, TilOMAN, K B. II !)KllI, llisrllpt ion and asynchrony' in early' par('nt· inlant inlnaction. In: 1'''\'l'h"""..ia! /Ii,,},. in Infanl-"Ill'imnTII ..nlal 'l'rllll"flf'll"II", ('d. ll. H. Sawin, H. ('. Hawkins, L. t'. Walk('r So .1, II, I'pnlicllil. :'\;pw York: BnllllH·r/:VlaZl·1. pp.!1] II!! . \\'EH:"EI(, F, E, '" S~lITII, H. S, I I!!';"';" I, I\.alllll'" ('hl/drl'n ('''711'' of A.~,' Honollllll: t'ni\,prsil\, of Hawaii I'r('ss.

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