ï‚⧠Grief May Delay the Attachment and Interaction With the Living Baby

Pediatrics. 2011 Feb; 127(2): 284–292.

Maternal Resolution of Grief Subsequently Preterm Nascency: Implications for Babe Zipper Security

Prachi E. Shah

^aDivision of Child Behavioral Health, Section of Pediatrics, Eye for Human Growth and Development, University of Michigan, Ann Arbor, Michigan;

Melissa Clements

^bChildren's Forum, Inc, Tallahassee, Florida; and

Julie Poehlmann

^cSection of Human Development and Family Studies, School of Human Ecology, and

^dWaisman Center, University of Wisconsin, Madison, Wisconsin

Abstract

OBJECTIVE:

This study explored the association between mothers' unresolved grief regarding their infant'southward preterm nascency and infant-mother attachment security. We hypothesized that mothers with unresolved grief would be more than likely to have insecurely fastened infants at xvi months and that this association would be partially mediated by maternal interaction quality.

METHODS:

This longitudinal study focused on 74 preterm infants (age of <36 weeks) and their mothers who were function of a larger study of loftier-risk infants. The present assay included assessment of neonatal and socioeconomic risks at NICU belch; maternal low, Reaction to Preterm Birth Interview findings, and quality of parenting at a postterm historic period of 9 months; and infant-mother zipper at postterm age of 16 months. Associations among findings of grief resolution with the Reaction to Preterm Nascence Interview, quality of parenting interactions, and attachment security were explored by using relative risk ratios and logistic and multivariate regression models.

RESULTS:

The relative risk of developing insecure attachment when mothers had unresolved grief was one.59 (95% confidence interval: 1.03–2.44). Controlling for covariates (adjusted odds ratio: 2.94), maternal feelings of resolved grief regarding the preterm nascence feel were associated with secure baby-female parent attachment at 16 months. Maternal grief resolution and interaction quality were independent predictors of attachment security.

CONCLUSION:

Maternal grief resolution regarding the experience of preterm birth and the quality of maternal interactions have important implications for emerging attachment security for infants born prematurely.

Keywords: zipper, grief, parent-child interactions, preterm, resolution

WHAT'South KNOWN ON THIS SUBJECT:

For mothers of children with chronic medical conditions or disabilities, such as epilepsy or cerebral palsy, a history of maternal unresolved grief regarding the child's diagnosis has been associated with insecure babe-mother attachment.

WHAT THIS STUDY ADDS:

Unresolved grief related to a preterm nascence is associated with the development of insecure infant-mother attachment. Mothers with resolved grief after preterm nascence are 2.9 times every bit likely to have deeply fastened infants, compared with mothers with unresolved grief.

Premature birth often is traumatic and a source of parental distress.^1,–3 This nonnormative transition to parenthood has been described as an "emotional crisis"⁴ that typically is characterized by feelings of loss and grief,^five,–vii which sometimes persist for months after the infant'due south NICU discharge.^1,viii,–xi In some means, accommodation to having a preterm infant is like to adaptation to having a child with a disability; the mother must adjust her expectations and hopes for her kid in the face of uncertainties, and she must mourn the hoped-for kid while nevertheless embracing the child she has.^12,thirteen The degree to which a female parent can resolve feelings of grief and loss regarding the premature delivery is thought to bear on the mother-child relationship.^4,6,nine,14

Persistent feelings of grief may affect a parent's ability to respond sensitively and contingently to the infant's cues,¹⁵ which may influence baby attachment. Attachment theory describes how a parent's interactive behavior influences later babe emotional development^16,17; contingently responsive and sensitive parenting contributes to secure infant attachment¹⁸ and better social/emotional development.¹⁹ Conversely, interactions lacking in sensitivity and responsiveness are associated with insecure attachment.²⁰ Preterm infants, especially those born with lower nascence weights or greater medical risks, seem to be at risk for developing insecure attachments.^21,–23 Insecure attachment is a nonspecific take chances for subsequently psychopathological atmospheric condition,^24,–26 whereas attachment security is related to subsequent social competence and empathy.^27,–29

The clan betwixt maternal grief resolution and attachment has been explored among children with diagnosed chronic medical conditions or disabilities by using the Reaction to Preterm Birth Interview (RPBI).^30,–33 The RPBI probes parents' feelings most the diagnostic process, the child's condition, and their reactions to the diagnosis. The interview results are coded as resolved or unresolved.³⁴ Since initial validation, associations betwixt RPBI grief resolution and the quality of parent-child interactions or zipper have been demonstrated for multiple clinical samples, including children with Down syndrome, autism, cerebral palsy, epilepsy, and phenylketonuria,^{31,–33,35,–38} but has not been explored for premature infants. Because feelings of grief are mutual amongst mothers of preterm infants^4,6 and because infant zipper predicts children's later social/emotional development,²⁵ it is important to identify associations between maternal grief regarding preterm birth and zipper, and so that vulnerable mother-infant dyads tin be identified and supported.

Nosotros hypothesized that mothers experiencing unresolved grief would be more than likely to have infants with insecure attachment, compared with mothers with resolved grief. We expected the association between grief resolution and security to persist later on adjustment for infant and maternal covariates identified a priori. Considering unresolved grief was associated previously with specific maternal behaviors (eg, frightening behavior),^39,–43 we also expected that the quality of maternal parenting at postterm age of ix months would partially mediate (ie, explain) the association betwixt maternal grief resolution at postterm age of ix months and attachment at postterm age of 16 months (Fig ane).

Hypothesized fractional arbitration model. SSP indicates strange situation process. A indicates the human relationship between the predictor (RPBI) and outcome (attachment); B, human relationship between the predictor (RPBI) and the intervening variable (PCERA); C, relationship between the intervening variable (PCERA) and result (attachment).

METHODS

Participants

70-four infant-mother dyads who are function of a larger longitudinal study¹¹ participated. All 74 infants were born preterm (<36 weeks of gestation).

For the larger report, 181 mothers and their infants were recruited from 3 Wisconsin NICUs in 2002–2005. Families were invited to participate if infants were at ≤35 weeks of gestation or weighed <2500 grand at birth and had no congenital or pregnant neurologic problems or prenatal drug exposures, on the footing of hospital screening (prenatal maternal interview and postnatal infant meconium assay and urine toxicological screen), and if mothers were ≥17 years of historic period, could read English, and self-identified as the child's main caregiver. For multiple births, ane baby was selected randomly for participation.

Lxx percent of the infants were white, 10% were black, i% was Middle Eastern, and 19% were multiracial. Babe nativity weights ranged from 490 to 3328 thousand (mean ± SD: 1744 ± 588 1000), gestational ages ranged from 25.0 to 35.viii weeks (hateful ± SD: 31.four ± 3.two weeks), and infants were hospitalized a mean ± SD of 33.4 ± 28.vii days. At NICU belch, mothers had a hateful ± SD age of 29.7 ± 5.9 years and 14.iii ± two.7 years of pedagogy. Most mothers (north = 54 [73%]) were married, and the mean ± SD family unit income was $56 541 ± $33 002. 30-viii infants (51%) were boys.

Procedures

This written report was approved past hospital and academy institutional review boards. Infants were assessed at 6 time points between NICU discharge and corrected age of 36 months (calculated on the basis of the baby'southward due appointment, as is commonly used for assessments of preterm infants).⁴⁴ This written report focuses on data obtained at the NICU discharge, 9-month, and 16-month time points. At NICU discharge, medical records were reviewed, and maternal demographic information was obtained. The 9-month habitation visit included observation of baby-female parent play, assessment of maternal depression, and an interview about the mother's preterm nativity feel (which was audiotaped and later transcribed). During the videotaped interaction, mothers were instructed to play "as they commonly would" for 15 minutes, and these interactions were later coded. The 16-month laboratory visit included assessment of baby attachment and maternal vocabulary.

Measures

Infant-Mother Attachment

Babe-mother attachment was assessed at postterm age of sixteen months by using the Strange Situation Procedure test described by Ainsworth et al.¹⁶ The Strange Situation Procedure exam is the standard method for assessing zipper among infants 12 to 18 months of historic period. The videotaped procedure includes a series of mother-child separations and reunions that arouse the infant's motivation to explore (when not distressed) and urge to seek proximity to the caregiver (when distressed). Classification is on the footing of 4 categories (secure, insecure-avoidant, insecure-resistant, and disorganized), as coded from the child's reunion behaviors.¹⁶ A trained attachment researcher who was blinded to the report variables coded the tapes. Ten tapes (14%) were coded past a second trained researcher, with a κ of 0.lxxx across the secure and insecure categories.

Maternal Grief Resolution

Mothers were interviewed at postterm age of nine months with the RPBI, a structured, standardized interview modified from the Reaction to Diagnosis Interview^thirty to focus on the feel of premature delivery. Similar the Reaction to Diagnosis Interview, the RPBI consists of five questions designed to arm-twist content and bear upon regarding the parent's view of the child's medical condition and prematurity (Table one). The questions probe the parent's thoughts and feelings almost the child's birth, the process leading to delivery, changes in those thoughts or feelings, and by and current thoughts regarding the causal office she or other factors might have played in her child's prematurity.

Tabular array 1

Reaction to Preterm Birth Interview

When did yous outset realize that [child's name] was going to be born prematurely?

What were your feelings at the fourth dimension of realization?

Take these feelings changed over time?

Tell me exactly what happened when you lot gave birth to [child's proper name's] prematurely. Where were y'all? Who else was there? What were you thinking and feeling at the moment?

Parents sometimes wonder or have ideas virtually why they have a child who was built-in prematurely. Do you take anything similar that that y'all wonder about? (Prompt if necessary: For example, some parents feel that they might accept done something to contribute to their child'south condition; others believe that God must have a reason for giving them this kid. What practise you lot wonder most?)

Each interview was coded according to the Reaction to Diagnosis Interview classification system³⁴ by trained individuals who were blinded to other family information. Interrater reliability between 2 raters was high (κ = 0.76) across 26 transcripts (35%). The results were categorized as resolved or unresolved.

Resolved grief reflect a focus on the present, an acceptance of the kid's status, a forward-looking orientation, an accurate representation of the child, and an acknowledgment of a modify in feelings since the premature nascence. Parents with resolved grief are no longer searching for a reason for the preterm birth and demonstrate an exclamation of "moving on in life." Parents with resolved grief are able to describe the child'south abilities accurately and can acknowledge the benefits and challenges of having a kid built-in prematurely.^34,45

Characteristics of unresolved grief include distortions of the child'due south status or unrealistic expectations about the child's prognosis. Parents with unresolved grief may demonstrate a connected search for reasons why the kid was born prematurely, and they frequently seem to be "stuck in the by." In telling their stories, parents with unresolved grief seem to be reliving the birth experience, only their narratives often lack details nigh their feelings or the events regarding the premature delivery. The emotional tone of the narrative seems overwhelmed or angry; parents with unresolved findings seem disengaged or cut off from the preterm birth experience, with minimization or denial of the touch of the feel on themselves.^34,45

Maternal Parenting Interactions

Infant-mother play interactions at nine months were coded with the 29 parenting variables of the Parent-Child Early Relational Cess (PCERA).⁴⁶ The PCERA is an observational coding system that has been used with preterm infants.⁴⁷ Variables are coded on a calibration of i (negative quality) to v (positive quality). Previous studies reported acceptable ranges of internal consistency (r = 0.75–0.96) and validity.⁴⁸ The 29 PCERA parent items were subjected to an unweighted, least-squares, exploratory, factor analysis with a varimax rotation with a 3-factor solution, similar to the theoretically derived subscales presented by Clark.⁴⁸ We labeled the factors positive touch on, advice, and connexion (cistron 1 [14 items]; α = .95), intrusiveness, anxiety, and insensitivity (factor 2 [8 items]; α = .89), and anger, hostility, and criticism (gene 3 [5 items]; α = .93). Higher scores reflected more-positive parenting; therefore, for factors 2 and 3, lower scores represented more intrusiveness and anger. Ten per centum of the sample was coded independently by 2 trained researchers. Interrater reliability ranged from 0.83 to 0.97 (mean: 0.88), similar to findings in previous studies.^49,50

Neonatal Health Risks

A standardized neonatal health risk index used with preterm infants¹¹ was calculated through review of NICU medical records. Infant gestational historic period and nativity weight were standardized, reverse-scored, and combined with the standardized sum of the presence of 10 neonatal medical risks (ie, apnea, respiratory distress, chronic lung disease, gastroesophageal reflux, multiple birth, supplementary oxygen treatment at NICU belch, apnea monitor employ at NICU belch, 5-minute Apgar score of <half-dozen, ventilation during NICU stay, and NICU stay of >30 days). The index had a Cronbach's α of .seventy, and scores ranged from −4.08 to 5.91 (mean ± SD: −0.12 ± 2.63), with higher scores reflecting more prematurity and neonatal health risks.

Family Socioeconomic Risks

A socioeconomic risk alphabetize was calculated past summing the presence of the following chance factors identified from the NICU demographic questionnaire: family income below federal poverty guidelines (adapted for family size), both parents unemployed, single mother, adolescent mother, >four dependent children, mother did not graduate from loftier school, and begetter did not graduate from loftier schoolhouse. Scores ranged from 0 to 7, with college scores reflecting more risks (Cronbach'due south α = .75).

Maternal Vocabulary

The Peabody Moving-picture show Vocabulary Test, 3rd Edition,⁵¹ was used to measure out maternal receptive vocabulary because the RPBI relies, in office, on the respondent's verbal skills. The Peabody Moving-picture show Vocabulary Exam is a widely used, individually administered assessment for individuals between ii and 90 years of age; it has a mean of 100 and a SD of fifteen, and results correlate strongly with IQ. In this sample, maternal Peabody Picture Vocabulary Test scores ranged from 76 to 136 (mean ± SD: 100.7 ± thirteen.3).

Maternal Depressive Symptoms

The Middle for Epidemiologic Studies-Depression Scale⁵² was used to appraise maternal depressive symptoms at 9 months. The Middle for Epidemiologic Studies-Depression Calibration is a twenty-item, cocky-report questionnaire that asks respondents to rate their symptoms in the previous week on a four-bespeak scale ranging from 0 (rarely/none of the fourth dimension) to 3 (most/all of the time). It is a well-validated measure used with high-take chances and depression-risk samples.⁵² For the nowadays study, Cronbach's α was .88.

RESULTS

Grief Resolution

Most mothers (67.six%) in our sample exhibited resolved grief on the RPBI. Groups with resolved and unresolved grief were like with respect to demographic characteristics (Tabular array 2).

TABLE 2

Characteristics of Mothers With Resolved Versus Unresolved Grief and Their Infants

	Resolved (N = 50)	Unresolved (Due north = 24)
Maternal variables
Historic period, range (mean ± SD), y	17–forty (30.5 ± v.ii)	17–42 (28.two ± 7.0)
Didactics, range (hateful ± SD), y	11–21 (14.3 ± ii.4)	eight–21 (fourteen.ii ± 3.3)
Yearly household income, range (mean ± SD), $	6000–146 000 (59 651 ± 30 145)	4320–140 000 (50 060 ± 38 158)
No. of dependents, range (mean ± SD)	1–eleven (2.1 ± 1.6)	1–five (2 ± i.1)
No. of family socioeconomic risk factors, range (hateful ± SD)	0–5 (0.8 ± 1.4)	0–5 (1.3 ± ane.7)
Depression score at 9 mo, range (mean ± SD)	0–30 (nine.2 ± 7.2)	0–24 (9.7 ± 6.9)
Peabody Picture Vocabulary Test standard score, range (hateful ± SD)	76–136 (100.9 ± 13.four)	76–131 (100.2 ± 13.4)
Marital status, northward (%)
Married	39 (78)	15 (62.5)
Not married	11 (22)	9 (37.five)
Kid variables
Gender, northward (%)
Male person	23 (46)	15 (62.5)
Female	27 (54)	9 (37.five)
Race, n (%)
White	38 (76)	fourteen (58.iii)
Blackness	four (8)	iii (12.five)
Hispanic	4 (viii)	two (8.iv)
Middle Eastern	1 (2)	0 (0)
Multiracial	3 (half dozen)	v (20.nine)
Multiple nativity, due north (%)
No	43 (86)	18 (75)
Yes	7 (fourteen)	half-dozen (25)
Birth weight, range (mean ± SD), g	490–3328 (1711 ± 584)	722–2802 (1812.6 ± 602.v)
Gestational age, range (mean ± SD), wk	25–356/7 (31< ± 33/seven)	25–356/vii (313/7 ± 31/seven)
Duration of hospitalization, range (hateful ± SD), d	four–105 (32.9 ± 29.7)	4–86 (34.3 ± 27.1)

Attachment Security

Half of the infants (n = 37) were classified as securely fastened to their mothers, whereas 14 (30%) were avoidant, 22 (nineteen%) were resistant, and 1 (1%) was disorganized (Fig 2). We used the binary variable of secure versus insecure (50% secure and fifty% insecure) in our analyses.

Distribution of attachment classifications (n = 74).

Clan Between RPBI Findings and Zipper

Data were analyzed past using PASW Statistics 17.0 (SPSS, Chicago, IL). After data screening to detect any statistical assumption violations, the clan betwixt resolution of grief and baby attachment classification was calculated for the 4 attachment groups (Tabular array 3). Nosotros then dichotomized infant zipper into secure/insecure categories, and the relative risk of insecure attachment was calculated (95% confidence interval [CI]). The relative chance of insecure attachment for infants of mothers with unresolved grief was 1.59 (95% CI: 1.03–ii.44) (Table iv).

Tabular array 3

Associations Between RPBI Grief Resolution and Child Attachment in 4-Style Classification

Grief Resolution	Attachment, due north
	Avoidant (Northward = fourteen)	Secure (N = 37)	Resistant (N = 22)	Disorganized (North = 1)
Resolved (N = l)	9	29	12	0
Unresolved (N = 24)	5	8	ten	1

Table four

Associations Between RPBI Grief Resolution and Child Attachment

Grief Resolution	Zipper, n
	Secure (N = 37)	Insecure (Due north = 37)
Resolved (N = 50)	29	21
Unresolved (N = 24)	8	16

To determine whether the RPBI grief-attachment association was decreased or altered by covariates that were identified a priori (neonatal health, family unit socioeconomic risk, maternal vocabulary, and maternal low), we estimated a hierarchical logistic regression model (adjusted odds ratio). Covariates were entered in the offset step and RPBI results in the second footstep, so that we could examine the respective inferential statistic (step two χ²) to determine the unique contribution of RPBI results to attachment, with adjustment for covariates. Every bit hypothesized, the RPBI results still significantly predicted infant zipper security afterwards adjustment for the 4 covariates (pace 2 χ₂ ¹ = 4.22; P = .040). When mothers demonstrated resolved RPBI grief, their infants experienced 2.nine times the odds of being classified as having secure attachment (Table 5).

Table 5

Hierarchical Logistic Regression Analyses of RPBI Status as Predictor of Baby Zipper Security

	Odds Ratio (95% CI)	P
Step ane
Neonatal wellness risks	1.00 (0.84–1.19)	.997
Family socioeconomic risks	1.07 (0.74–1.54)	.458
Maternal vocabulary	1.02 (0.97–i.06)	.439
Maternal depression at 9 mo	1.10 (0.94–ane.10)	.627
Pace ii
Neonatal health risks	one.00 (0.83–ane.20)	.997
Family socioeconomic risks	one.xvi (0.78–one.71)	.458
Maternal vocabulary	1.02 (0.98–1.07)	.351
Maternal depression at 9 mo	i.02 (0.94–one.10)	.636
RPBI grief resolution	2.94 (1.02–eight.47)	.046

Maternal Parenting as Potential Mediator of Relationship Betwixt RPBI Findings and Attachment

Nosotros then tested whether the association between RPBI results of resolution and attachment was partially mediated by maternal interaction quality, according to regression methods described by Baron and Kenny.⁵³ For demonstration of mediation (Fig 1), (ane) the predictor (RPBI results) must exist related to the outcome (attachment), (2) the predictor must be related to the intervening variable (PCERA), and (3) the human relationship between the intervening variable and the outcome should be stronger than the relationship between the predictor and the outcome. The logistic regression analysis reported above tested the first criterion. To test the second criterion, nosotros conducted 3 linear regression analyses, with the RPBI results predicting each PCERA factor. These analyses indicated that the RPBI results did non predict maternal interaction quality, which ruled out the second criterion of our mediator model (Table six). Because the method described past Businesswoman and Kenny⁵³ for detecting mediator furnishings has been criticized for having low power, we also tested the model by using a articulation significance examination.⁵⁴ The results were virtually the same equally those reported here.

Tabular array half-dozen

Linear Regression Analyses Predicting Maternal Interaction Quality

Consequence Variable	Predictor Variable	B, Gauge ± SE (95% CI)	β	P
PCERA gene 1 (positive affect and advice)	RPBI condition	0.40 ± 0.26 (−0.11–0.92)	.18	.12
PCERA cistron 2 (intrusiveness and anxiety)	RPBI status	0.15 ± 0.24 (−0.34–0.63)	.07	.55
PCERA factor 3 (acrimony and hostility)	RPBI status	0.04 ± 0.23 (−0.41–0.49)	.85	.85

Maternal Parenting and Attachment

To test the tertiary criterion of the mediator model, we conducted a logistic regression assay predicting attachment for each PCERA gene, with parenting quality entered in step three of the models (adjusted odds ratio). In these logistic regression models, meliorate parenting (ie, more-positive touch [gene 1], less intrusiveness [cistron 2], and less acrimony [gene 3]) significantly increased the odds of baby attachment security (Table 7). The RPBI results connected to predict xvi-month infant attachment in the models with PCERA factors 2 and three, although the RPBI results decreased to trend-level significance (P = .059) in the model with PCERA factor i (positive affect) (Fig 3).

Tabular array 7

Hierarchical Logistic Regression Analyses of PCERA Factors 1, 2, and iii every bit Predictors of Infant Attachment Security

Predictor Variables	Odds Ratio (95% CI)	P
Model ane (step 3 χii i = 5.01; P = .025)
Neonatal wellness risks	0.96 (0.79–one.16)	.644
Family socioeconomic risks	1.35 (0.88–ii.09)	.172
Maternal vocabulary	1.01 (0.97–1.06)	.542
Maternal depression	1.03 (0.95–i.eleven)	.505
RPBI grief resolution	ii.89 (0.96–eight.73)	.059
PCERA factor one (positive affect and advice)	1.87 (1.05–3.32)	.033
Model ii (stride 3 χ2 1 = nine.82; P = .002)
Neonatal health risks	0.90 (0.73–i.11)	.326
Family socioeconomic risks	ane.41 (0.91–2.19)	.123
Maternal vocabulary	i.02 (0.97–1.08)	.348
Maternal depression	1.05 (0.96–one.14)	.282
RPBI grief resolution	iii.39 (1.08–x.63)	.036
PCERA factor 2 (intrusiveness and anxiety)	2.66 (one.36–five.23)	.004
Model 3 (footstep 3 χii 1 = 10.85; P = .001)
Neonatal health risks	0.90 (0.73–one.10)	.309
Family socioeconomic risks	one.50 (0.94–2.39)	.086
Maternal vocabulary	1.02 (0.97–1.07)	.499
Maternal depression	1.03 (0.95–1.12)	.446
RPBI grief resolution	4.02 (1.24–13.05)	.020
PCERA factor 3 (anger and hostility)	three.03 (1.46–six.30)	.003

Maternal positive interactions and resolved grief as predictors of infant security. SSP indicates foreign situation procedure; CI, conviction interval.

Give-and-take

The present report contributes to our agreement of attachment in preterm infants past focusing on maternal grief resolution. A female parent's unresolved grief regarding her child'south preterm birth was associated with afterward insecure babe-female parent attachment. In addition, maternal interaction quality predicted attachment security, although it did not mediate the association between grief resolution and attachment.

At postterm age of 9 months, nigh one-third of mothers expressed unresolved grief regarding their infant's preterm birth, consequent with research describing how maternal feelings of stress and trauma regarding a preterm delivery can persist long afterward NICU belch.^one,10,14 Yet, when mothers resolved their feelings of grief, their children experienced virtually 3 times the odds of developing a secure attachment by xvi months. These results extend the findings of previous studies that demonstrated an association betwixt maternal grief resolution regarding a kid's chronic illness and attachment.^xxx,–33 Our analyses suggest that resolution of grief seems to take a protective effect on the development of secure infant attachment, with the majority of securely attached infants having mothers with resolved grief. However, the association between unresolved grief and the evolution of insecure attachment may be more than circuitous, with grief resolution existence simply one component that influences later on attachment.

Previous studies focusing on grief resolution included parents who knew the severity of and prognosis for the child'due south condition.^30,45 In contrast, a preterm infant's prognosis frequently is non known for months or years⁵⁵; therefore, the process of resolution of grief after preterm birth may be complex and may vary with the child'south subsequent development. In our study, grief resolution was unrelated to the severity of infant medical run a risk, which suggests that it is not the level of medical complications at NICU belch that contributes to maternal resolution of grief.

Building on previous inquiry linking unresolved loss, maternal interactions, and insecure attachment,^40,41 we hypothesized that the association between maternal grief resolution and baby zipper would be partially mediated by maternal interactive beliefs. Although we did non discover bear witness for mediation, maternal interaction quality was an independent predictor of infant attachment. Consequent with previous enquiry,¹⁸ we plant that affectively positive, sensitive, and responsive maternal behavior was associated with secure attachment, whereas intrusive, broken-hearted, and hostile parenting was associated with insecurity.

The lack of clan between maternal unresolved grief and the quality of parenting interactions (ie, the 2nd criterion in the arbitration model) merits additional exploration. There are several explanations for why a mediating effect was non observed. The relationships betwixt unresolved grief, atypical maternal behavior, and insecure attachment were exhibited most characteristically in previous research under circumstances of significant pathological conditions, for example, when maternal behavior was frightening and when the attachment classification was disorganized.^40,42 Our sample had only 1 baby with disorganized attachment, which prevented us from exploring this association in greater depth. In addition, mothers with unresolved grief may not demonstrate frightening behaviors under situations of low stress,³⁹ and the free-play episode in which maternal interactive behavior was coded might not have been stressful enough to arm-twist the low-incidence, maladaptive parenting behaviors associated with insecure attachment.

Information technology besides is possible that experiencing unresolved grief with regard to having a preterm baby at postterm age of 9 months does not translate into demonstrating broken-hearted, intrusive, insensitive, or angry parenting behaviors at the aforementioned time bespeak. The finding that the RPBI findings decreased to trend-level significance in the model focusing on maternal positive affect, advice, and connectedness (Fig 3) suggests that additional research should focus on the potentially protective effects of positive parenting for preterm infants. Finally, information technology is possible that the link between resolved loss and secure zipper in preterm infants occurs through positive parenting behaviors (eg, positive affect and connectedness) in a variety of contexts, rather than through the absenteeism of frightening or negative behaviors.

One important limitation of the study was the relatively small sample size of 74 dyads, which did not permit for more in-depth analysis of pathways and moderators that contribute to grief resolution and attachment security. Although the rate of attrition was relatively low (15%), families that remained in the report were somewhat more socioeconomically advantaged than those lost to attrition. Because we focused on preterm infants, our results are not generalizable to term infants. This written report used an adaptation of the Reaction to Diagnosis Interview rather than the original mensurate because of the population studied. In assessing maternal adaptation to preterm birth, we did not focus on specific medical diagnoses considering children in the report typically did not have such diagnoses at NICU discharge. Finally, we did not include fathers, who tin can be important in mothers' accommodation to parenthood and primal attachment figures for children.

CONCLUSIONS

This written report suggests that resolution of grief regarding preterm birth and the quality of early parent-babe interactions are meaning predictors of infant attachment security for infants born preterm. Currently, the process through which mothers resolve their grief after a preterm birth is not known. Furthermore, it is not clear whether the constructs of resolution of grief regarding preterm birth and the quality of early dyadic interactions can exist assessed by a pediatric provider in the context of a follow-upward visit for these high-hazard infants. Boosted research is needed to explore the factors that contribute to grief resolution after preterm birth and to decide whether resolution of grief and the factors influencing maternal adaptation to preterm birth can be explored successfully in the context of a pediatric visit.

In addition, the function of anticipatory guidance in pediatric visits (ie, highlighting the baby'southward developmental capacities and prognosis, reflecting with the parents on the impact of the child's condition on the parents, and exploring and optimizing the female parent's experience of social support^thirty,45) to facilitate resolution of grief is an area in need of exploration. Some other opportunity for intervention may include using mental wellness resources to assistance the parents integrate the experience of grief regarding the preterm nascency with their ongoing parental roles.^56,57

ACKNOWLEDGMENTS

This research was supported past grants from the National Institutes of Wellness (grant HD44163) and the University of Wisconsin.

Special thanks go to the children and families who generously gave of their time to participate in this study.

Financial DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Funded by the National Institutes of Wellness (NIH).

RPBI

Reaction to Preterm Nascency Interview

PCERA

Parent-Child Early on Relational Cess

CI

confidence interval

REFERENCES

i. Singer LT, Salvator A, Guo Southward, Collin M, Lilien 50, Baley J. Maternal psychological distress and parenting stress later the birth of a very depression-birth-weight infant. JAMA. 1999;281(9):799–805 [PubMed] [Google Scholar]

ii. Vanderbilt D, Bushley T, Young R, Frank DA. Acute posttraumatic stress symptoms among urban mothers with newborns in the neonatal intensive intendance unit: a preliminary study. J Dev Behav Pediatr. 2009;30(ane):50–56 [PubMed] [Google Scholar]

3. Davis L, Edwards H, Mohay H, Wollin J. The impact of very premature birth on the psychological wellness of mothers. Early on Hum Dev. 2003;73(ane–2):61–70 [PubMed] [Google Scholar]

four. Caplan G, Stonemason EA, Kaplan DM. Four studies of crisis in parents of prematures. Customs Ment Health J. 1965;ane(2):149–161 [PubMed] [Google Scholar]

5. Shaw RJ, Deblois T, Ikuta 50, Ginzburg K, Fleisher B, Koopman C. Astute stress disorder among parents of infants in the neonatal intensive care nursery. Psychosomatics. 2006;47(iii):206–212 [PubMed] [Google Scholar]

6. Kaplan DM, Mason EA. Maternal reactions to premature nativity viewed every bit an acute emotional disorder. Am J Orthopsychiatry. 1960;thirty(iii):539–552 [PubMed] [Google Scholar]

7. Macey TJ, Harmon RJ, Easterbrooks MA. Affect of premature nascency on the development of the infant in the family. J Consult Clin Psychol. 1987;55(six):846–852 [PubMed] [Google Scholar]

8. Latva R, Korja R, Salmelin RK, Lehtonen Fifty, Tamminen T. How is maternal recollection of the birth feel related to the behavioral and emotional event of preterm infants? Early Hum Dev. 2008;84(9):587–594 [PubMed] [Google Scholar]

9. Pierrehumbert B, Nicole A, Muller-Cypher C, Forcada-Guex G, Ansermet F. Parental post-traumatic reactions later premature birth: implications for sleeping and eating problems in the baby. Arch Dis Child Fetal Neonatal Ed. 2003;88(v):F400–F404 [PMC free commodity] [PubMed] [Google Scholar]

ten. Kersting A, Dorsch G, Wesselmann U, et al. Maternal post-traumatic stress response afterward the birth of a very low birthweight infant. J Psychosom Res. 2004;57(5):473–476 [PubMed] [Google Scholar]

11. Poehlmann J, Schwichtenberg AJM, Commodities D, Dilworth-Bart J. Predictors of depressive symptom trajectories in mothers of preterm or low birth weight infants. J Fam Psychol. 2009;23(five):690–704 [PMC free article] [PubMed] [Google Scholar]

12. Emde RN, Brown C. Adaptation to the nascence of a Downwards'south syndrome babe: grieving and maternal attachment. J Am Acad Child Psychiatry. 1978;17(two):299–323 [PubMed] [Google Scholar]

13. Stengel TJ. Infant beliefs, maternal psychological reaction, and mother-infant interactional issues associated with the crunch or prematurity: a selected review of the literature. Phys Occup Ther Pediatr. 1982;2(2–three):3–24 [Google Scholar]

14. Muller-Nil C, Forcada-Guex Thousand, Pierrehumbert B, Jaunin L, Borghini A, Ansermet F. Prematurity, maternal stress and mother-child interactions. Early Hum Dev. 2004;79(2):145–158 [PubMed] [Google Scholar]

15. Forcada-Guex G, Pierrehumbert B, Borghini A, Moessinger A, Muller-Nix C. Early dyadic patterns of mother-infant interactions and outcomes of prematurity at 18 months. Pediatrics. 2006;118(i). Available at: www.pediatrics.org/cgi/content/full/118/one/e107 [PubMed] [Google Scholar]

sixteen. Ainsworth MDS, Blehar MC, Waters Eastward, Wall South. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum; 1978 [Google Scholar]

17. Bowlby J. Attachment and Loss, Vol 1: Attachment. New York, NY: Basic Books; 1969 [Google Scholar]

xviii. De Wolff MS, van Ijzendoorn MH. Sensitivity and attachment: a meta-analysis on parental antecedents of babe attachment. Child Dev. 1997;68(four):571–59 [PubMed] [Google Scholar]

19. Sroufe LA. The part of infant caregiver attachment in development. In: Belsky J. ed. Clinical Implications of Attachment. Hillsdale, NJ: Erlbaum; 1988:18–xl [Google Scholar]

twenty. Isabella RA. Origins of attachment: maternal interactive behavior across the first year. Child Dev. 1993;64(2):605–621 [PubMed] [Google Scholar]

21. Cox SM, Hopkins J, Hans SL. Attachment in preterm infants and their mothers: neonatal risk status and maternal representations. Babe Ment Wellness J. 2000;21(half dozen):464–480 [Google Scholar]

22. Mangelsdorf SC, Plunkett JW, Dedrick CF, et al. Attachment security in very low birth weight infants. Dev Psychol. 1996;32(5):914–920 [Google Scholar]

23. Brisch KH, Bechinger D, Betzler S, Heinemann H. Early preventive attachment-oriented psychotherapeutic intervention program with parents of a very low birth weight premature infant: results of attachment and neurological evolution. Attach Hum Dev. 2003;5(2):120–135 [PubMed] [Google Scholar]

24. Dark-green J, Goldwyn R. Annotation zipper disorganization and psychopathology: new findings in attachment research and their potential implications for developmental psychopathology in childhood. J Child Psychol Psychiatry. 2002;43(7):835–846 [PubMed] [Google Scholar]

25. Sroufe LA, Carlson EA, Levy AK, Egeland B. Implications of attachment theory for developmental psychopathology. Dev Psychopathol. 1999;11(i):i–thirteen [PubMed] [Google Scholar]

26. Warren SL, Huston 50, Egeland B, Sroufe LA. Child and boyish anxiety disorders and early zipper. J Am Acad Kid Adolesc Psychiatry. 1997;36(5):637–644 [PubMed] [Google Scholar]

27. Pianta R, Egeland B, Sroufe LA. Maternal stress and children'south evolution: prediction of schoolhouse outcomes and identification of protective factors. In: Rolf JE, Masten A, Cicchetti D, Nuechterlein K, Weintraub Due south. eds. Hazard and Protective Factors in the Development of Psychopathology. New York, NY: Cambridge University Press; 1990:215–235 [Google Scholar]

28. Sroufe LA. Infant-caregiver zipper and patterns of adaptation in preschool: the roots of maladaptation and competence. In: Perlmutter Yard. ed. Minnesota Symposium in Child Psychology Hillsdale, NJ: Erlbaum; 1983;xvi:41–91 [Google Scholar]

29. Sroufe LA. Relationships, self, and private adaptation. In: Sameroff AJ, Emde RN. eds. Relationship Disturbances in Early Babyhood: A Developmental Approach. New York, NY: Basic Books; 1989:165–190 [Google Scholar]

thirty. Marvin RS, Pianta RC. Mothers' reactions to their child'due south diagnosis: relations with security of attachment. J Clin Kid Psychol. 1996;25(4):436–445 [Google Scholar]

31. Barnett D, Clements M, Kaplan-Estrin M, et al. Maternal resolution of kid diagnosis: stability and relations with child attachment beyond the toddler to preschool transition. J Fam Psychol. 2006;20(1):100–107 [PubMed] [Google Scholar]

32. Barnett D, Hill Hunt Thou, Butler CM, McCaskill JW, IV, Kaplan-Estrin M, Pipp-Siegel S. Indices of attachment disorganization amid toddlers with neurological and non-neurological problems. In: Solomon J, George C. ed. Attachment Disorganization. New York, NY: Guilford Press; 1999:189–212 [Google Scholar]

33. Oppenheim D, Koren-Karie N, Dolev S, Yirmiya N. Maternal insightfulness and resolution of the diagnosis are associated with secure attachment in preschoolers with autism spectrum disorders. Child Dev. 2009;80(2):519–527 [PubMed] [Google Scholar]

34. Pianta RC, Marvin RS. Transmission for Classification of the Reaction to Diagnosis Interview. Charlottesville, VA: University of Virginia; 1993 [Google Scholar]

35. Barnett D, Vondra JI. Atypical attachment in infancy and early childhood among children at developmental hazard, part I: atypical patterns of early on attachment: theory, research and current directions. Monogr Soc Res Child Dev. 1999;64(iii):i–24 [PubMed] [Google Scholar]

36. Pianta RC, Marvin RS, Morog MC. Resolving the past and present: relations with zipper organization. In: Solomon J, George C. ed. Attachment Disorganization. New York, NY: Guilford Press; 1999:379–398 [Google Scholar]

37. Lord B, Ungerer J, Wastell C. Implications of resolving the diagnosis of PKU for parents and children. J Pediatr Psychol. 2008;33(8):855–866 [PMC complimentary article] [PubMed] [Google Scholar]

38. Schuengel C, Rentinck ICM, Stolk J, et al. Parents' reactions to the diagnosis of cerebral palsy: associations betwixt resolution, age and severity of disability. Child Care Health Dev. 2009;35(5):673–680 [PubMed] [Google Scholar]

39. Jacobvitz D, Leon G, Hazen N. Does expectant mothers' unresolved trauma predict frightened/frightening maternal behavior? Risk and protective factors. Dev Psychopathol. 2006;18(2):363–379 [PubMed] [Google Scholar]

40. Schuengel C, Bakermans-Kranenburg MJ, van Ijzendoorn MH. Frightening maternal beliefs linking unresolved loss and disorganized baby attachment. J Consult Clin Psychol. 1999;67(1):54–63 [PubMed] [Google Scholar]

41. Madigan S, Moran G, Schuengel C, Pederson DR, Otten R. Unresolved maternal attachment representations, disrupted maternal behavior and disorganized attachment in infancy: links to toddler behavior issues. J Child Psychol Psychiatry. 2007;48(ten):1042–1050 [PubMed] [Google Scholar]

42. Madigan Due south, Bakermans-Kranenburg MJ, van Ijzendoorn MH, Moran 1000, Pederson DR, Benoit D. Unresolved states of mind, anomalous parental beliefs, and disorganized zipper: a review and meta-analysis of a transmission gap. Adhere Hum Dev. 2006;8(2):89–111 [PubMed] [Google Scholar]

43. Primary M, Hesse E. Parents' unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening parental beliefs the linking mechanism? In: Greenberg MT, Cicchetti D, Cummings EM. eds. Attachment in the Preschool Years: Theory, Inquiry, and Intervention. Chicago, IL: University of Chicago Press; 1990:161–184 [Google Scholar]

44. DiPietro JA, Allen MC. Interpretation of gestational age: implications for developmental enquiry. Child Dev. 1991;62(5):1184–1199 [PubMed] [Google Scholar]

45. Pianta R, Marvin RS, Britner PA, Borowitz KC. Mothers' resolution of their children's diagnosis: organized patterns of caregiving representations. Infant Ment Wellness J. 1996;17(3):239–256 [Google Scholar]

46. Clark R. The Parent-Child Early Relational Assessment: Instrument and Manual. Madison, WI: University of Wisconsin; 1985 [Google Scholar]

47. Pridham K, Steward D, Thoyre Southward, Chocolate-brown R, Brownish L. Feeding skill performance in premature infants during the starting time twelvemonth. Early Hum Dev. 2007;83(5):293–305 [PubMed] [Google Scholar]

48. Clark R. The Parent-Kid Early Relational Cess: a factorial validity study. Educ Psychol Mensurate. 1999;59(5):821–846 [Google Scholar]

49. Clark R, Hyde JS, Essex MJ, Klein MH. Length of maternity exit and quality of female parent-infant interactions. Child Dev. 1997;68(2):364–383 [PubMed] [Google Scholar]

50. Pridham KF, Brown R, Clark R, Sondel South, Green C. Infant and caregiving factors affecting weight-for-age and motor evolution of full-term and premature infants at ane year mail service-term. Res Nurs Health. 2002;25(5):394–410 [PubMed] [Google Scholar]

51. Dunn 50, Dunn 50. Peabody Picture Vocabulary Test III. Circle Pines, MN: American Guidance Service; 1997 [Google Scholar]

52. Radloff LS. The CES-D Calibration: a self-written report depression scale for enquiry in the general population. Appl Psychol Measure. 1977;i(3):385–401 [Google Scholar]

53. Businesswoman RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):1173–1182 [PubMed] [Google Scholar]

54. MacKinnon D, Lockwood C, Hoffman J, West South, Sheets V. A comparison of methods to examination mediation and other intervening variable furnishings. Psychol Methods. 2002;7(i):83–104 [PMC free article] [PubMed] [Google Scholar]

55. Grunau RE, Whitfield MF, Davis C. Design of learning disabilities in children with extremely low birth weight and broadly average intelligence. Arch Pediatr Adolesc Med. 2002;156(half dozen):615–620 [PubMed] [Google Scholar]

56. Driscoll JW. Maternal parenthood and the grief process. J Perinat Neonatal Nurs. 1990;four(two):one–10 [PubMed] [Google Scholar]

57. Klass D. The deceased kid in the psychic and social worlds of bereaved parents during the resolution of grief. Death Stud. 1997;21(ii):147–175 [PubMed] [Google Scholar]

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025424/

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