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Supporting Parent-Infant Relationships and Infant Health

Outcomes: Concepts and Research Studies

Karen PridhamUniversity of Wisconsin-Madison School of Nursing

Funding: Herma Heart Center, Children’s Hospital of Wisconsin; Children’s Hospital of Wisconsin Foundation; National Institute of Nursing Research, grant R03 NR0272

Research Team

• Tondi Harrison University of Minnesota

• Mary KrolikowskiChildren’s Hospital of Wisconsin

• Roger Brown University of Wisconsin-Madison

• Kathleen Mussatto– Children’s Hospital of Wisconsin

Contributors• Mary Elizabeth Bathum

– Edgewood College

• Raymond Fedderly– Medical College of Wisconsin

• Jill Winters– Columbia College of Nursing

• Lioness Ayres– University of Iowa

• Inge Bretherton– University of Wisconsin-Madison

Purposes of the Research with Parents and Infants/Young Children with a Congenital, Birth, or Chronic Condition

• Identify contextual factors that increase or diminish risk

• Examine mechanisms of competence (adaptive caregiving/feeding; attuned parenting; emotional, behavioral, and physiologic regulation)

• Examine the trajectory of these mechanisms, contextual factors, and outcomes through early childhood

• Test interventions for improved outcomes

Sources translated from other disciplines to clinical settings/problems

• Guided participation– Relationship based, social-cultural approach to learning

and development of competence in everyday, non-formal settings

• Internal working model of parenting– Formulated by Bowlby to explain the parent-child

attachment/caregiving relationship• Attunement, regulation, and negotiation as outcomes

• An example of guided participation:

Theoretical Model of the Guided Participation Intervention

Context

ParentWell Being

ChildIllness

SeverityFamily (Dyadic)Problem-Solving

Processes

Outcomes

Child Development,

Growth

Parent and Child Feeding

Behavior

Guided Participation in Caregiving (Feeding)

Support of Mothers in Feeding their Premature Infants

Aim of guided participation (GP): Develop feeding competencies for 42 mothers and infants weighing 1500 g or less at birth Examine the difference between randomly assigned GP and Standard Care groups

Procedure: GP started with the first oral feedings in the special care nursery and continued in home visits by a nurse through the first post-term year.Competencies were assessed from videotaped feeding at 1, 4, 8, and 12 months using the Parent-Child Early Relational Assessment (Clark, 1999).

Results: GP effect on competencies was significant for mothers at 4 months and for infants at 1 and 8 months.

Conclusions from the Guided Participation Intervention Research

• Guided participation effect was small on both maternal and infant feeding behavior.

• The groups were heterogeneous in infant, parent, and family context.

• Mothers’ response to guided participation varied widely.

• How mothers thought about the infant, themselves, and feeding needed exploration.

The Internal Working Model Concept• Parents differ in how they think about and represent the reality of feeding

their babies.• A parent’s way of thinking and representation of reality may make a difference

in her feeding behavior.• What a parent says about feeding or expresses during feeding reveals her

internal working model.

Internal Working Model

• A mechanism of learning, developing, and becoming competent that nurses can access and address

• Domain of mental functioning formed through the child-parent relationship and carried forward into adult relationships

• Organizes and regulates perception, interpretation of information, and judgment about meaning, and directs (goal-corrects) action

• Concerns a parent herself in relationship, child and others, and the task or goal itself

• Theoretically, a mediating variable between contexts and outcomes.

Internal Working Model Concept in the Attachment and Caregiving BehaviorSystems

Expectations

Intentions

Emotions

Meaning

Motivations Caregiving Behavior

Internal Working Model

Attachment Behavior

Listening for Information About a Mother’s Internal Working Model in her Talk or Narrative

A Mother and Her 12-Month-Old Son with a Heart Defect

Study of internal working models of parenting or caregiving

Goal: Develop a Typology of Internal Working Models

Typology: classes or types for naming a parent’s internal working model (IWM).

Typing (naming)Variables for mixed-model analyses

Study the relationship

to/effect on risk

Design tailored, patient- and family-

centered interventions

Continued development and refinement of the

typology

Theoretical Model to Develop an Internal Working Model Typology

Context

ParentWell Being

ChildIllness

Severity

Family Processes

Internal Working Model of Parenting

Child, Parent Feeding

Competencies

Study of an Internal Working Model

Develop a semi-structured interview protocol:• What are these mothers experiencing? What do they

expect? Want to accomplish? Intend to do?

Developing a TypologyDirected content analysis of the transcribed interview• Two or more people read the entire interview• Looked for the activities the parent was working on or accounts of the mental

work the parent was doing (e.g., figuring something out, coming to a resolution)

• Described the parent’s expectations, intentions, emotions, and meanings in relation to this behavioral or mental activity

• Named the motivation expressed in this description, staying close to the parent’s own words.

• Labeled the motivation with a class, according to a dictionary of IWM terms we were developing

• Prepared a matrix of classes, eventually 9 of them, one line for each family and one matrix for each interview time

MF Matrix for 1 Month

Baby Directed

Parent-Directed

Task Directed

Family Promoting/ facilitating baby physically, cognitively, socially, emotionally

Guarding, protecting

Relating, being with baby

Strengthening family

Protecting Self

Promoting, facilitating self

Promotiing parenting identity

Making it through

Doing the needed

40151 X X X X 40351 X X40451 X X X X 40452 X X X X X 40551 X X X X40751 X X 50151 X X X X X X50152 X X 50351 X X X50951 X X X X X X X50952 X X X X X 50953 X X 51051 X X 51151 X X X 51251 X X X X51252 X X 60151 X X60251 X X X 60351 X X 61051 X X 61052 X X X X61151 X X X X X X 61152 X X X X X 61251 X X X X 70151 X X

Motivations of Parents of Infants with a Complex Congenital Heart Defect at 12 Months of Age

Baby Directed

Parent-Directed

Task Directed

Family

Promoting/ facilitating baby physically, cognitively, socially, emotionally

Guarding, protecting

Relating, being with baby

Strengthening family

Protecting Self

Promoting, facilitating self

Promoting, parenting identify

Making it through

Doing the needed

40151 x X X X X X40351 X X X X X40451 X X X 40452 X X X X X 40551 X X X X X X X40751 X x X x x50151 X X X X X

50152Baby died in hospital

50351 X X X X X50951 X X X X50952 X X X X X 50953 X X X X X X 51051 X X X 51151 X X X X51251 X X X X 51252 X X X X X X 60151 X X X X 60251 X X X X X 60351 X X X X X 61051 X X X X 61052 X X X61151 X X X 61152 X X X X X 61251 X X X X X

70151 Baby died in hospital

Theoretical Model of the Research: Future Test of a Guided Participation Intervention

Context

ParentWell Being

ChildIllness

Severity

Family (Dyadic)Processes

Guided Participation Intervention

Outcomes: Child, Parent, Family

Child Development, Physiologic &

Behavioral Regulation

Parent Adaptive Feeding Behavior

Family Adaptive Interaction

Satisfaction/Quality of Life

Feeding as the Context of Parenting/Caregiving

Implications for Research and Clinical Practice with Parents and Infants

• Support of parents in learning and developing caregiving skills and practice in the context of a relationship with their children is a new area of study. It requires collaboration with other disciplines and translational research to address questions concerning guided participation and its effects on outcomes.

• Knowledge of internal working models of caregiving may provide clinical bases for supporting parents’ learning.

• How the child’s pysiologic and behavioral regulation affects caregiving and the difference the quality of caregiving makes for infants and young children is undeveloped territory for research.

Supporting Parent-Infant Relationships and Infant Health Outcomes