Journal of Pediatric Psychology, Vol. 26, No. 2, 2001, pp. 93-104
© 2001 Society of Pediatric Psychology
Parenting Stress in Mothers of Very-Low-Birth-Weight (VLBW) and Full-Term Infants: A Function of Infant Behavioral Characteristics and Child-Rearing Attitudes
1 University at Albany, State University of New York, 2 Albany Medical College
All correspondence should be sent to Leslie F. Halpern, University of Albany, Dept. of Psychology, Social Science 112, State University of New York, Albany, New York 12222. E-mail: lhalpern{at}csc.albany.edu .
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Abstract |
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Objective: To examine the moderating effects of child-rearing attitudes on the relation between parenting stress and infant behavioral characteristics for mothers of very-low-birth-weight (VLBW) and full-term infants.
Methods: Fifty-six 9-month-old infants (23 VLBW and 33 full-term) and their mothers were the participants. Mothers completed measures of parenting stress, child-rearing attitudes, infant temperament, and infant behavioral problems.
Results: The VLBW infants had a higher frequency of behavioral problems, and their mothers reported more child health concerns than the mothers of the full-term infants. Regression analyses showed that the relation between parenting stress and infant distress was moderated at medium and high levels of parental strictness for only the VLBW infants.
Conclusions: The amount of stress the mothers of the VLBW infants experienced was a result of the congruence between their infant's behavioral characteristics and their own child-rearing attitudes.
Key words: VLBW infants; parenting stress; child-rearing attitudes; temperament; behavioral problems.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Substantial literature describes the numerous challenges that parents face following the birth of a premature infant. Their experiences typically evoke considerable distress concerning the infant's medical condition, survival, and developmental prognosis. Even after the medical crisis has passed and the infant leaves the hospital, parents may continue to experience distress as they attempt to care for a biologically fragile infant whose behavioral cues are frequently difficult to interpret (Goldberg & Marcovitch, 1986
; Macey, Harmon, &
Easterbrooks, 1987). Recent improvements in medical technology are
facilitating the survival of many more biologically vulnerable infants.
Subsequently, parents are now often caring for very-low-birth-weight (VLBW)
infants with chronic and severe medical conditions that require them to adapt
to periods of prolonged stress (Singer,
Danviller, Bruening, Hawkins, & Yamashita, 1996). Much of the
research literature on parental adaptation to the preterm infant has focused
on mothers' psychological adjustment using a variety of indicators, including
measures of psychological distress, depression and/or anxiety, parenting
stress, and distorted perceptions, such as perceived child vulnerability.
Unfortunately, the current literature yields few conclusions about mothers'
adjustment because few studies have included control groups, and most have
focused on mothers' adjustment near the time of infant birth or within the
first few months of the infant's life. This study sought to contribute to this
literature by examining the parenting stress experienced by mothers of VLBW
infants and full-term infants in the second half of the infants' first year of
life.
Uncontrolled studies that have assessed the psychological reactions of
mothers of preterms during infant hospitalization or within the first few
months of life have reported that mothers experience heightened distress, with
concerns for their infant's health noted most frequently
(Hughes & McCollum, 1994;
Pederson, Bento, Chance, Evans, & Fox,
1987). Singer et al.
(1996) compared the
psychological distress of mothers of VLBW infants, with and without
bronchopulmonary dysplasia, with the amount of distress reported by the
mothers of a group of full-term infants during the first few months of life.
They found that the mothers in both groups of VLBW infants reported more
pregnancy and illness stressors and greater psychological distress than the
mothers of the term infants. The degree to which infant biological risk status
exacerbates mothers' distress in the period following their infant's birth
remains unclear, for even studies that have compared the distress experienced
by mothers of relatively healthy preterm infants with that of mothers of
full-term infants report significant group differences
(Trause & Kramer,
1983).
The few studies that have examined mothers' psychological adjustment beyond
the period of immediate crisis have included primarily relatively healthy
preterm infants. These studies have found that the mothers of preterm and
full-term infants report no significant differences in life stress, parenting,
and life satisfaction at 1 month (Crnic,
Ragozin, Greenberg, Robinson, & Basham, 1983), maternal
distress and parenting self-efficacy at 4 months
(Halpern & MacLean, 1997),
and maternal distress at 7 months (Trause
& Kramer, 1983). Research involving low-risk preterm infants,
therefore, seems to indicate that the increased amounts of distress initially
experienced by the mothers of preterm infants diminishes over time to levels
comparable to that experienced by mothers of healthy full-term infants.
Nonetheless, with the survival of greater numbers of biologically at-risk
infants, and the paucity of controlled studies, the question of whether
mothers of VLBW preterms experience greater distress than mothers of full-term
infants beyond the newborn period remains unanswered.
Parenting, as Belsky (1984)
suggested, is influenced by aspects of the individual parent, the individual
child, and the social context in which the parent-child relationship is
embedded. Similarly, parenting stress is also likely to be affected by
parental and child characteristics, as well as features of the family's social
context. The child's contribution to parenting stress seems clear, with
challenging cumulative daily interactions between the mother and child
yielding increased stress. Research on the behavioral characteristics of
preterm infants has repeatedly shown that they differ from full-term infants
in ways that make them more challenging social partners
(Beckwith, 1990); thus, their
mothers are likely to be at greater risk for experiencing increased distress.
Studies that have examined the relation between infant factors and mother's
adjustment have focused almost exclusively on the infant's biological risk
factors (e.g., Thompson, Oehler, Catlett,
& Johndrow, 1993; Singer
et al., 1996) and have typically ignored the contribution of the
infant's behavioral attributes. The lack of studies examining the
contributions of preterm infants' behavioral characteristics to mothers'
parenting experiences is surprising, particularly in light of the frequently
reported association between increased infant temperamental difficultness and
greater psychological distress reported by the mothers of full-term infants
(e.g., Cutrona & Troutman,
1986; Halpern & MacLean,
1997; Vaughn, Bradley, Joffe,
Seifer, & Barglow, 1987).
Research that has examined the contributions of maternal factors to
mothers' parenting experiences has primarily focused on the influence of
demographic characteristics such as maternal education, marital status, and
socioeconomic status (SES) (e.g., Blumberg
1980; Brooten et al.,
1988). Abidin
(1990) has suggested that
research on parenting stress needs to move beyond main effect models to
examine more complex interactive models of parenting stress that consider
parental personality factors, cognitions, and perceptions affecting parenting
stress. A few studies that moved beyond a focus on mothers' demographic
characteristics investigated the relations between mothers' perceptions of
their roles within the parenting context and parenting stress. These studies
found no significant differences between the mothers of preterm and full-term
infants in either maternal self-efficacy
(Halpern & MacLean, 1997;
Singer et al., 1996) or
perceived role restriction (Singer et al.
1996); however, these factors were significantly related to
maternal distress, particularly for mothers of preterms.
One aspect of mothers' cognitions, largely neglected with respect to its
influence on parenting stress, is mothers' child-rearing beliefs or attitudes.
Parental attitudes toward child rearing play a salient role in child
developmental outcomes (Sameroff &
Seifer, 1983). Research has demonstrated that mothers'
child-rearing attitudes show considerable consistency over time for both
younger (Roberts, Block, & Block,
1984) and older children
(Nally, Eisenberg, & Harris,
1991), and mothers' self-reported attitudes correspond with their
childrearing behaviors (Kochanska,
Kuczynski, & Radke-Yarrow, 1989). Much of the research on
parent child-rearing attitudes and beliefs has evolved out of Baumrind's
conceptualization of parenting styles (for reviews, see
Baumrind, 1989;
Darling & Steinberg,
1993). Studies on parenting attitudes have fairly consistently
demonstrated that an authoritarian parenting approach, characterized by
restrictive behaviors and coercive disciplinary practices, is associated with
poor social and academic adaptation in children. Preschool-age and early
elementary school-age children whose parents report using harsh or restrictive
discipline and coercive parenting have greater peer relationship problems, are
more aggressive, show diminished social competence
(Crockenberg, Jackson, & Langrock,
1996; Hart, DeWolf, Wozniak,
& Burts, 1992; Pettit,
Clawson, Dodge, & Bates, 1996), and perform poorly
academically (Pettit, Bates, & Dodge,
1997). Parents' use of harsh and ineffective parenting practices
has also been found to distinguish clinic-referred preschool boys with
behavior problems from comparison group boys
(DeKlyen, Biernbaum, Speltz, &
Greenberg, 1998).
Restrictive parenting has been found to be exhibited more by parents from
lower than higher SES backgrounds (Pettit
et al., 1996; Pettit et al.,
1997); however, both SES and restrictive parenting appear to
contribute independently to child outcomes
(Pettit et al., 1996).
Researchers examining the relation between parenting styles and children's
academic performance have noted that authoritarian parenting may not have the
same negative consequences for minority youths that it does for
European-American children (e.g.,
Dornbush, Ritter, Liederman, Roberts,
& Fraleigh, 1987; Pettit
et al., 1997; Steinberg,
Lamborn, Darling, Mounts, & Dornbush, 1994). Recently,
however, Kelly, Smith, Green, Berndt, and Rogers
(1998) found that the toddlers
of low- and working-income African American fathers who held a restrictive
parenting attitude showed poorer cognitive and social development than the
children of fathers who held a less restrictive attitude. Such findings
suggest that authoritarian attitudes may be particularly detrimental to child
outcomes regardless of ethnicity and economic class early in life.
Of the few studies that have examined the parenting attitudes of mothers of
preterm infants, most have focused on positive parenting attitudes such as
feelings of warmth regarding child rearing (e.g.,
Greenberg & Crnic, 1988;
Landry, Garner, Swank, & Baldwin,
1996). Because of the association between mothers' child-rearing
attitudes and their child-directed behaviors, child-rearing attitudes likely
also play a key role in the amount of stress mothers experience as parents. A
goal of this study was to test a "behavior-attitude congruence
model" that proposes that the potential negative effects of a child's
behaviors on the caregiver's parenting experiences are moderated by the
caregiver's child-rearing attitudes. In this model, authoritarian mothers of
behaviorally challenging infants are more likely to experience increased
parenting stress than less authoritarian mothers of challenging infants.
Although parenting stress may also negatively affect children's behaviors,
this investigation focuses on child-rearing attitudes as a
"filter" of caregivers' experiences with their children. Thus, the
model proposed in this study explains one direction of a likely bi-directional
process.
Because VLBW infants are described in the literature as behaviorally
challenging, the behavior-attitude congruence model would stipulate that the
child-rearing attitudes of the mothers of VLBW infants should moderate the
relation between the infant's behavioral characteristics and the mother's
stress. As infants become increasingly skilled crawlers after 6 months of age,
their negative encounters with caregivers increase because the infant's desire
for mobility conflicts with the caregiver's concerns for safety. Moreover, it
is the infant's new-found independence that likely prompts parents' tendencies
to restrict their infant's actions in later infancy. The key purpose of this
study was to investigate whether mothers of VLBW infants experience more or
less stress than mothers of full-term infants in the second half of their
infant's first year of life. Consistent with Abidin's
(1990) recommendations, our
goals were to move beyond main effect models of parenting stress to (1)
examine the moderating effect of mothers' child-rearing attitudes on the
relation between mothers' reports of challenging infant behavioral
characteristics and parenting stress, and (2) discover any group differences
in these processes.
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Method |
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Participants
Fifty-six 9-month-old infants (23 VLBW <1500 gm and 33 normal birth weight >2500 gm full terms) and their mothers participated in this study. All this study's participants were involved in a longitudinal project on the behavioral outcomes of VLBW infants that began when infants were 9 months of age (corrected for prematurity for the VLBW infants). Three additional families were assessed at 9 months, but mothers did not complete questionnaire packets and were therefore not included in this study. The VLBW infants and their parents were recruited in person or by phone from the newborn follow-up program of a children's hospital. Full-term infants born in the same hospital were randomly selected through medical record review, and their parents were contacted by phone. Infants with known chromosomal disorders, congenital infections, major anomalies, and congenital syndromes were excluded from this study. Infants whose mothers were diagnosed at pregnancy with mental illness, mental retardation, or with a significant history of alcohol or other substance use were also excluded from this study.
Infant demographic characteristics were similar across the two groups: 35%
of the infants in the VLBW group were boys as were 36% in the full-term group.
Although a slightly greater percentage of the infants in the VLBW group (53%)
were first-born (38% in the full-term group), this difference was not
statistically significantly (p >.05). The groups were also similar
in ethnic composition; most of the infants in both groups were Caucasian (79%
and 94% for the VLBW and full-term infants, respectively). Within the VLBW
group, 10.5% of the infants were African American and 10.5% were Hispanic.
Within the full-term group, 6% of the infants were Asian. Risk scores were
computed for the VLBW infants based on medical record review of infants'
neonatal risk factors (newborn data were not available for two infants who
were not born at Albany Medical Center) and ratings on the Modified Hobel
Neonatal Risk Index (Hack & Breslau,
1988). The mean risk score for the group was 29.55 (SD =
15.78), and scores ranged from 5 to 70. The infants experienced a wide range
of neonatal complications, with 38% having Apgars of <6 at 1 or at 5
minutes, 71% diagnosed with respiratory distress syndrome, 57% with apnea, and
29% with another respiratory condition (e.g., BPD, pheumonia); 71% of the
infants experienced some central nervous system problem (e.g., meningitis,
microcephaly, IVH, GMH, PVL), 62% had either anemia and/or jaundice, and 33%
had an infection.
Mothers in both groups were similar in age (VLBW, M = 32.37,
SD = 7.35 ; full-term, M = 32.44, SD = 4.50) and
years of education (VLBW, M = 14.37, SD = 2.87; full-term,
M = 15.53, SD = 2.21). The percentage of married mothers of
the VLBW infants (74%) was significantly less than the percentage of married
mothers in the full-term group (94%) (X[1] = 4.05, p =.044).
The families also differed significantly in SES. The families of VLBW infants
had significantly lower raw scores on Hollingshead's Index of Social Status
(Hollingshead, 1975) than the
families of the full-term infants (VLBW, M = 43.87, SD =
16.05; full-term, M = 52.32, SD = 12.47; t[49] =
-2.77, p =.008). Examination of the social class indices indicated
that all social classes were represented in the VLBW group: 78% of the
families from the full-term group were in the middle and upper social
classes.
Measures
Children's Behavioral Characteristics. The Infant Behavior
Questionnaire (IBQ; Rothbart,
1981) is a commonly used 94-item parent report instrument that
assesses infant temperament at 3, 6, 9, and 12 months of age. Parents are
asked to rate how often their infants exhibited specific behaviors during the
past week on a 7-point likert scale ranging from 1 ("never") to 7
("always"). For this study, four of the questionnaire's subscales
that assess infants' emotional characteristics were used: Distress to
Limitations, which measures children's crying or showing distress when
frustrated; Fear, which measures distress and latency to approach intense or
novel stimuli; Soothability, which measures children's reduction of crying or
distress when parents use soothing techniques; Smiling and Laughter, which
measures smiling and laughter in any situation. Rothbart has shown that this
measure has high internal consistency, with a median coefficient 
of.75.
The Infant Behavior Inventory (IBI;
Halpern & Mattis, 1994) is
a 42-item questionnaire used to assess the behavioral difficulties of infants
between 4 and 24 months of age. Parents rate the frequency with which specific
infant behaviors occur on a 7-point likert scale ranging from 1
("never") to 7 ("always"). Parents also rate whether
each behavior is a problem for them. If the behavior is seen as a problem, the
item is given a score of 1, if not, a 0. The parents' responses to the
frequency items yield a Total Behavior Problem scale score, and their problem
ratings yield a Total Perceived Problem scale score. These summary scores are
calculated by summing the raw values for all individual items in the measure.
In addition, based on a factor analysis of the IBI, subscales that measure
infant Anger, Moodiness, Activity Level, and Attentiveness can be computed.
The measure's authors reported moderate to high internal consistency for the
four subscales, with alphas ranging from.68 for Attention to.84 for Anger.
Because this study included only 9-month-old infants, the internal consistency
of the IBI scales were computed. These analyses revealed that coefficient
alphas for the Total Behavior Problem Frequency and Total Perceived Problem
scales were.83 and.89, respectively. Analyses also showed that the coefficient
alphas for the subscales were.83 for Anger,.69 for Moodiness,.60 for Activity
Level, and.39 for Attentiveness. Due to their low alpha coefficients, Activity
Level and Attentiveness were not used in later analyses.
Measures of Mothers' Characteristics. The Parenting Stress
Index-Short Form (PSI-SF; Abidin,
1995) is a frequently used 36-item self-report measure designed to
assess parents' feelings regarding their role as a parent. This measure yields
several subscales as well as a Total Stress score, which indicates the overall
level of stress the parent is experiencing. The Total Stress score was used to
assess mothers' parenting stress for this study. The PSI-SF Total Stress score
has been shown by the measure's author to have a high level of internal
consistency, with a coefficient alpha of.91.
The Parenting Attitudes Towards Childrearing Questionnaire (PACR;
Easterbrooks & Goldberg,
1984), considered an excellent measure of parenting attitudes (for
a review, see Holden & Edwards,
1989), is a 51-item self-report instrument designed to assess
issues salient for parents of young children. Parents are asked to indicate
how much they agree with statements regarding their attitudes on the topics of
child independence and expression of emotion, parental expression of
affection, discipline, and aggravation on a 7-point likert scale from 1
("strongly disagree") to 6 ("strongly agree"). The
PACR yields four subscales: Warmth, Encouragement of Independence, Strictness,
and Aggravation. Because this measure has been used primarily with the parents
of toddlers, coefficient alphas were computed for this sample. These analyses
yielded coefficient alphas of.11 (Warmth),.57 (Encouragement of
Independence),.72 (Strictness), and.72 (Aggravation). Given these findings, we
used only the Strictness and Aggravation scales in later analyses.
Procedure
The families of the VLBW infants were approached either in person during a
visit to the newborn follow-up program or were contacted over the phone. All
mothers of full-term infants were first contacted by phone. Interested parents
were sent information packets that included the informed consent forms. Once
informed consent was obtained from the infants' mothers, questionnaire packets
were mailed to the family about 1 week prior to a home visit scheduled for
when the infants were 9 months of age. As part of the home visit, a research
assistant completed an interview with the mother to gather family demographic
information. After the home visit, families were given a small toy for their
infant.
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Results |
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Group Differences
Analyses of covariance (ANCOVAs) with SES and marital status as the covariates were completed to test for group differences in infant and maternal characteristics. The means and standard deviations of the study's measures appear in Table I. Based on mothers' reports, the ANCOVAs showed that the VLBW group had a significantly higher IBI Total Behavior Problem score, F(1, 52) = 3.28, p <.05, and a significantly higher IBI Moodiness score, F(1, 52) = 2.96, p <.05, than the full-term infant group. No significant group differences were found for infant temperament characteristics, parenting stress, or parenting attitudes. (A power analysis indicated that, based on an effect size of.40, with Type I error [alpha] of.05 and a power of.80, an average sample size of 26 participants per group would be sufficient to detect a significant effect for group comparisons [Cohen, 1988
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Correlational Analyses
Using correlational analyses, we examined the relations between mothers'
reports of their infants' behavioral characteristics and mothers' parenting
stress and attitudes within both infant groups. As shown in
Table II, the analyses revealed
a considerable number of significant correlations between infant temperament,
the behavior problem variables, and mothers' parenting stress and attitudes
within the VLBW group. The mothers of VLBW infants who reported greater
parenting stress had infants with higher Total Behavior Problem and Total
Perceived Problem scores, and they described their infants as more angry and
more moody. The mothers of VLBW infants who perceived a greater number of
their infant's behaviors as problematic reported using a stricter
child-rearing approach, and they experienced greater parental aggravation.
Also, mothers who described their infants as more angry reported increased
parental aggravation. Within the VLBW group, infant temperament was also
significantly related to parenting stress but not to parenting strictness or
aggravation. The mothers of VLBW infants who were more distressed, more
fearful, more difficult to soothe, and who smiled less reported greater
parenting stress. Within the full-term group, fewer significant relations
between infants' behavioral characteristics and parenting stress and attitudes
were detected. Analyses found that only increased infant anger and greater
temperamental fear were significantly related to increased parenting stress.
Two-tailed z tests used to examine group differences in the magnitude
of the effect sizes showed that only the correlations between the Total
Perceived Problem score and both parental strictness and parenting stress were
significantly stronger for the VLBW infants than for the full-term infants
(p <.05).
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A series of correlational analyses were also completed in order to more closely examine the contribution of infant biological risk status to the VLBW infants' behavioral characteristics and their mothers' parenting characteristics. The results of these analyses showed that VLBW infants with higher biological risk scores were described as more angry (r =.37, p <.05), their mothers perceived a greater number of infant behaviors as problematic (r =.41, p <.05), and trends were noted for increased total behavior problems (r =.34, p <.07) and greater moodiness (r =.35, p <.06). Those infants with higher risk scores were also described as showing greater temperamental distress (r =.39, p <.05) and greater fear (r =.44, p <.05). Finally, the mothers of infants who were more biologically vulnerable at birth reported increased parenting stress (r =.41, p <.05).
Regression Analyses
We used multiple regression procedures to examine the behavior-attitude
congruence model, particularly the extent to which parental strictness
moderated the relations between both mothers' reports of infant temperamental
fear and distress and parenting stress for the VLBW and full-term infants.
Variables for the regression were selected based on theoretical interests and
the results of correlational analyses. We selected the parental Strictness
variable for the regression analyses rather than parental Aggravation because
the Strictness scale most clearly assesses mothers' authoritarian
child-rearing attitudes, whereas the Aggravation scale primarily assessed
mothers' feelings about their interactions with their infant. Temperament
variables were selected to represent the infants' behavioral characteristics
instead of the behavior problem variables because (1) parental strictness and
mothers' descriptions of infant temperament were not significantly related in
either group, thus minimizing statistical problems associated with
multicollinearity in regressions, and (2) the items on the IBQ scales were
designed to capture "normative"variability in infants' behavioral
repertoires, whereas the items on the IBI were designed to assess a narrower
range of behaviors likely to challenge infants' caregivers. The temperament
variables of Fear and Distress were specifically selected for the regressions
because they reflect aspects of the infants' behavioral repertoire that may
most broadly affect the mothers' parenting experiences. Moreover, of the four
temperament variables measured, both Fear and Distress were significantly
related to infants' Total Behavior Problem Scores for the VLBW (r
=.85, r =.72, p <.001, respectively) and the full-term
infants (r =.56, r =.48, p <.01,
respectively).
The scores for the infant temperament variables and parental strictness
were first mean centered to create deviation scores (see
Jaccard, Turrisi, & Wan,
1990), and then the product terms of the centered scores were
calculated. (The product terms of continuous variables were used in the
interaction analyses to maintain variability in the data
[Cohen & Cohen, 1983;
Jaccard, Turrisi, & Wan,
1990].) Two regressions were then completed in which parenting
stress was regressed on the covariates (marital status and SES status), one of
the two infant temperament variables (Fear or Distress), parental strictness,
the 2-way interaction terms (Parental Strictness x Infant Temperament,
Group x Parental Strictness, Group x Infant Temperament), and the
3-way interaction term (Group x Parental Strictness x Infant
Temperament).
The result of the regression analysis involving infant fear was stastically significant (R =.69, R2 =.48), F(9, 46) = 4.64, p <.001; however, because the regression coefficient for the 3-way interaction term was not statistically significant (p >.05), the analysis was not examined further. The analysis regressing parenting stress on infant distress was statistically significant (R =.67, R2 =.44), F(9, 46), = 4.07, p <.01, and the 3-way interaction term regression coefficient was also statistically significant (B = -1.986, t = -2.79, p <.01). These findings were then investigated more closely by examining the relation between parenting stress and infant distress as moderated by parental strictness within each infant group. The slopes of parenting stress on infant distress at three levels of parental strictness for the VLBW and full-term groups appear in Table III and are depicted in Figures 1 and 2, respectively. Examination of the slopes and corresponding t ratios in Table III reveals that for the VLBW infants the slope of parenting stress on infant distress was stastically significant when parental strictness was at a medium and high level but not at a low level. As depicted in Figure 1, the mothers of VLBW infants who reported using a stricter parenting approach (at medium to high levels of strictness), whose infants' had higher temperamental distress, experienced greater parenting stress than mothers who were also higher in strictness but whose infants had lower temperamental distress. The relation between parenting stress and infant distress did not vary significantly at low levels of parental strictness. In contrast to the findings for the VLBW group, for the full-term group, only a marginally significant effect was found for the slope of parenting stress on infant distress when parental strictness was low. The slopes for the full-term group appear in Figure 2 and suggest that, at low levels of parenting strictness, the mothers of more distressed infants experience greater stress than mothers of infants low in distress. The regression results suggest that parental strictness did not significantly moderate the relation between infant distress and parenting stress for mothers of full-term infants to the degree it did for the VLBW infants. Finally, a more detailed examination of the changes in slopes for the two groups revealed that for every 1 unit change in parental strictness (based on the measure's raw scores), the slope of parenting stress on infant distress increases by 0.862 for the VLBW group and decreases by 1.12 for the full-term group.
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Discussion |
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Studies that have examined mothers' psychological adjustment to the birth of a VLBW infant have primarily focused on the period immediately following the infant's birth, and the few that have examined these processes later in the first year have not included control groups. One of the goals of this study was to compare the parenting stress reported by mothers of VLBW infants with that of mothers of full-term normal birth weight infants in the second half of the first year of life. This study failed to detect significant mean differences in the amount of parenting stress reported by mothers of VLBW infants and full-term infants, yet within the VLBW group, biological risk status was associated with increased stress. The lack of group differences suggests that the increased distress commonly experienced by mothers of VLBW infants during the newborn period (Singer et al., 1996
) may diminish with the passage of time. As suggested
by Thompson et al.'s (1993)
research, mothers' concerns for their infants' health likely contribute
strongly to parenting stress during the newborn period, but with time,
mothers' stress becomes increasingly associated with factors commonly
experienced by all mothers. Because this study did not measure parenting
stress from the newborn period, it is unclear whether the stress reported by
the mothers of the VLBW infants decreased or that of the mothers of the
full-term infants increased over time. Alternatively, the lack of group
differences in parenting stress may be due to the heterogeneity of our VLBW
group's biological risk status. Because the mothers of VLBW infants who had
experienced more medical problems reported greater stress, it is likely that
the severity of infants' medical complications, not the fact that they are
VLBW, contributes to increased parenting stress. Therefore, the degree to
which VLBW infants experience medical problems is likely to affect group
comparisions of parenting stress. The question of the relation between infant
biological risk status and parenting stress would clearly benefit from
additional exploration by studies that include groups of both high- and
low-risk VLBW infants, as well as full-term controls.
The results of this study revealed few significant group differences in
mothers' reports of their infants' behavioral characteristics; those that were
detected emerged in the assessment of infants' behavioral difficulties.
Results showed that the VLBW infants were described as having a greater
frequency of behavioral problems and higher moodiness scores. The Moodiness
scale contains items that assess aspects of infant behavioral instability;
thus, in addition to showing increased behavioral difficulties, the VLBW
infants seem to be more erratic in their display of affect and behavior,
which, in turn, increases the likelihood of caregiving challenges. This
study's failure to detect significant differences in infant temperament was
actually comparable to virtually all other research studies that have examined
temperament in preterms beyond 6 months of age using questionnaire methods
(e.g., Oberklaid, Prior, & Sanson,
1986; Ross, 1987;
Roth, Eisenberg, & Sel,
1984). However, because studies that previously failed to detect
temperament differences later in infancy included primarily low-risk preterms,
the lack of group differences was somewhat surprising, given that the preterm
sample in this study included VLBW infants. Although the groups did not differ
in their mean temperament ratings, this study demonstrated individual
differences within the VLBW group, with temperament varying as a function of
infant biological risk status. Analyses showed that those VLBW infants with
higher newborn risk scores were rated by their mothers as showing greater
temperamental distress and fear than VLBW infants with lower risk scores.
Others have similarly reported significant relations between biological risk
factors and preterm infant temperament
(Garcia Coll, Halpern, Vohr, Seifer, &
Oh, 1992; Ross,
1987) and differences in preterm infant temperament as a function
of infant risk status groupings (Plunkett,
Cross, & Meisels, 1989).
As expected, infants' behavioral characteristics were significantly related to parenting stress within both groups. For the mothers of VLBW infants, increased parenting stress is associated with caring for an infant described as having greater behavioral difficulties, more temperamental distress and fear, poorer soothability, and less positive affect. Within the full-term group, fewer significant correlations were detected, as only increased infant anger and temperamental fear were significantly related to greater parenting stress. These results show that infants' behavioral characteristics affect the degree of stress experienced by all mothers but appear particularly salient for mothers of VLBW infants.
This study's goal of demonstrating a behavior-attitude congruence model was
partially realized. As expected, mothers experienced parenting stress not
solely as a function of the child's behavioral characteristics per se but as a
result of the match between the child's behavioral characteristics and the
mother's child-rearing attitudes. Regression results showed that the relation
between parenting stress and infant temperament was moderated by the mothers'
child-rearing attitude, but these relations were significant only within the
VLBW group. For the mothers of VLBW infants, increased infant distress was
associated with greater parenting stress when mothers' strictness was at
medium and high levels but not at a low level. When mothers who hold a
stricter child-rearing approach are paired with an infant who becomes
frequently distressed, they are more likely to experience greater parenting
stress. Significantly, even high levels of infant distress do not appear to
adversely affect mothers' parenting experiences, so long as the mothers hold a
less strict child-rearing attitude. Additional support for this model is
provided by the recent findings of Hastings and Rubin
(1999), who found that the
authoritarian mothers of aggressive toddlers responded to vignettes of
preschoolers' aggression with greater negative affect and suggested they would
use more power assertive disciplinary interventions than mothers who did not
have an authoritarian attitude. Apparently certain parenting attitudes may
increase mothers' vulnerability to their children's behavioral
characteristics.
We can only speculate about why the behavior-attitude congruence model was significant only for the mothers of VLBW infants. As we noted, infants' behavioral difficulties and temperament did not show the same consistency of relationship to parenting stress for the mothers of the full-term infants as it did for the mothers of the VLBW infants. Because the mothers of VLBW infants are exposed to highly stressful events pertaining to their infant's health and survival, they may become more attentive to their infant's behavioral displays than mothers of full-term infants. This heightened vigilance may promote a greater sensitivity to the infant's behavioral characteristics as well as to their own parenting attitudes, each in turn affecting mothers' parenting experiences. Indeed, this study's finding that mothers of VLBW infants who were more medically vulnerable described them as more temperamentally distressed and fearful, and their behaviors more problematic, suggests that the model we tested may be particularly relevant for high-risk VLBW infant-caregiver dyads. For full-term infants, the infants' behavioral characteristics were associated with the degree of parenting stress mothers reported; however, other environmental factors not measured in this study may have been more strongly associated with their parenting experiences.
This study provided new insights into factors that contribute to parenting stress for mothers of VLBW and full-term infants later in infancy. Shortcomings of this study included its sole reliance on parent report measures and a relatively small sample size. Future research in this area would benefit from the inclusion of observational measures of infants' behavioral characteristics to examine whether mothers' parenting stress is the byproduct of perceived or "real" infant behavioral characteristics. Finally, longitudinal research in needed to elucidate how the relationships among infant characteristics, mothers' child-rearing attitudes, and parenting stress evolve over the course of the infant's first year of life and beyond.
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Acknowledgments |
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This work was supported in part by a FRAP awarded to Dr. Halpern from the University of Albany, State University of New York. We thank Heather Lehman for her assistance in data collection and James Jaccard for his statistical advice.
Received July 26, 1999; revision received January 4, 2000; accepted May 23, 2000
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