Journal of Primary Prevention, 2(3), Spring, 1982
Perinatal Support Programs: A Strategy for the Primary Prevention of Child Abuse E L L E N B. G R A Y ABSTRACT." Perinatal support programs are offering new hope for the prevention of child abuse. This article reviews the research stimulating these programs, details the prescribed components of perinatal programs according to the Interprofessional Task Force on Health Care of Women and Children and the National Committee for Prevention of Child Abuse, and discusses four demonstration projects currently being conducted.
An exciting phenomenon is occurring now all over the country: the development of perinatal support programs in child welfare agencies, mental health centers, obstetricians' offices, preparation for childbirth series, hospitals, public health clinics, volunteer agencies, and combinations of these settings. The trend is exciting for a nunber of reasons, not the least of which is the truly multi-disciplinary participation in this movement to provide an optimally close and comforting environment for the parents and child to get to know and fall in love with each other. Doctors, nurses, educators, counselors, social workers, psychologists, and psychiatrists are embracing this implementation of over ten years of research for essentially the same reasons. As one professional put it, "I worked with children with problems for twenty-five years and it seemed that no matter at what point I was getting them, I was too late." It has been said before, b u t it is no less true in the area of child rearing: it is far easier to prevent than to treat. American society approaches the task of bringing up children with considerable ambivalence. We cannot seem to decide how seriously to take the idea of a science of child rearing. From blaming mother for the child's every developing characteristic, we move to recognizing that mother's needs affect the baby and that we therefore must be nonEllen B. Gray is Program Associate for Primary Prevention and Director of the project, "Collaborative Research and Community and Minority Group Action to Prevent Child Abuse," at the National Committee for Prevention of Child Abuse. Reprint requests may be addressed to the author at the National Committee for Prevention of Child Abuse, 332 South Michigan Avenue, #1250, Chicago, Illinois 60604. 0278-095X(82)1300-0138500.95
138
@1982 Human Sciences Press
Ellen B. Gray
139
critical of her. From a heavy-handed dissemination of new research indicating that certain modern conveniences--anesthesia, bottles, formula--are not as good for baby as the old-fashioned ways, we shift back to a recognition of the social, financial, and political stresses women suffer and a consequent letting up on mothers. And now to the latest discoveries that even in the earliest moments of life, the motherinfant relationship is critical. There is sometimes only a fine line between putting into practice the exciting up-to-the-minute discoveries of researchers in the field, and putting excessive and damaging pressure on the parents. That is why this newest piece of child development, this whole notion of "bonding" and "attachment" offers such hope. It is the positive nature and the fundamental reciprocity of the concept that is so different and encouraging. It is the idea that what is best for the baby in this instance is the same thing that makes child rearing easiest and most enjoyable for the mother. We are thinking now that perhaps this simple but elusive process of human attachment will prevent the eventuality of mother's and child's needs being constantly at odds, a situation common in child abuse cases; and we are acting to promote this attachment.
Research Although this program emphasis is relatively new, it is grounded in more than a decade of research. One thrust of this research involves the capabilities of the newborn. A number of studies, for example, have debunked the myth that newborns cannot see. On the contrary, Brazelton {1973}, Fantz, Fagan, and Miranda {1975), and Wolff {1966} have shown that immediately after birth, humans can focus, track, and discriminate a face-like pattern. Meltzoff and Moore {Note 1) found that for a brief period of time after birth, the infant can imitate facial expressions presented to him. Eisenberg (1976} has shown that infants prefer human voices and speech patterns to less meaningful noises, and Condon and Sander {1974) showed that the infants move in synchrony with these speech patterns. The Brazelton demonstrations {1973} show that the infant has an amazing amount of control over his own "state" and manages the environment in this way. He can shut out disturbing stimuli and can regulate his alertness to attend to people and objects. Another category of research leading to perinatal support programming discloses the automatic reciprocal responses between mother and baby. Irritable infant crying elicits a response from
140
Journal of Primary Prevention
mother that was measured by Gregg, Haffner, and Korner 11976). Mother picks the child up and rests him at her shoulder. This in turn quiets him and produces visual alertness, which is pleasing to the mother. Emde, Swedberg, and Suzuki {1975} and McLaughlin, O'Connor, and Deni {Note 2) showed a significantly prolonged alert state in the first hour post-partum {provided silver nitrate drops to the eyes are delayed}. Separate studies in the United States {Wolff, 1969} and Africa (Konner, 1972) have shown that the pain cry brings forth particularly prompt and concerned response by adults, and although we don't need research to know that if an infant smiles, we smile back, there is now scientific backup for this, also. Building on these findings of readiness for interaction of mother and child right after birth has been the discovery that this is the optimal and critical time for the attachment process to begin, and that sucessful mother-child bonding may play a vital role in preventing future parenting disturbances. Dr. Marshall Klaus and his associates i1972} of Case Western Reserve University School of Medicine studied a group of twenty-eight women who had just had their first babies, normal healthy infants. Half of the group received the routine contact with their babies which was allowed by most hospitals--a glimpse of the child immediately after birth, another short contact six to twelve hours later, and then every four hours, a twenty- to thirty-minute visit. The other half of the group had an opportunity for early contact consisting of receiving the baby, nude, with a heat panel for an hour during the first three hours after birth and five additional hours per afternoon for the three days following delivery. The mothers were observed feeding their infants, were interviewed, and had physical examinations on three occasions after three months. The mothers who received only routine contact were still "distant" from their infants at that time, displaying significantly less attachment behavior {looking at and smiling at the baby, holding and caressing him} than the early contact group. This apparent bonding may be attributable to the "maternal-sensitive" period that Klaus, Jerauld, Kreger, McAlpine, Steffa, and Kennell {1972} and others have postulated. It may be due also to the heightened state of alertness and responsiveness of the baby that Desmond, Rudolph, and Phitaksphraiwan (1966} found to exist in the first hour of life. In a latter study, Kennell, Jerauld, Wolfe, Chesler, Kreger, McAlpine, Steffa, and Klaus {1974} showed that the differences in attachment behavior between mothers having early and extended contact with their newborns and mothers having only routine contact were strikingly observable at one year. Ringler, Kennel, Jarvella, Navojosky, and
Ellen B. Gray
141
Klaus (1975} showed that even linguistic behavior of children can be affected b y immediate post-natal contact. Mothers were shown to engage in much more sophisticated verbal interactions with their twoyear-olds if they had had an opportunity for such contact. Even the lower animals provide data for the empirical underpinnings of current perinatal support programming. Ethologist Konrad Lorenz (1967} spells out the phylogenetic relationship between aggression and love. Extensive studies led him to conclude that within every one of those species which have developed "the bond" {the enduring ties that unite members} there are biological mechanisms for inhibiting or transforming aggression in the service of love. Professor and child analyst Selma Fraiberg t1967) establishes the parallel with humans by reminding us of the institution studies of Freud and Burlingham {1944) and Provence and Lipton {1962} that showed in the ill-mothered children, impulsivity, intolerance for frustration, rages and tantrums far out of proportion to "normal" children their age. "Where there are no human bonds," she writes, "there is no motive for redirection, for the regulation and control of aggressive urges." Fraiberg is talking of the "diseases of non-attachment" and of the hollow men and women who result from this lack in infancy. Child abuse clearly falls within the purview of these aggression diseases, and child abusers are more often than not the hollow men and women she describes. If we believe all of this evidence, we know that babies are ready to establish that love bond at birth. We know that the earlier the attachment process begins and the more time that mother and baby spend together during this crucial period, the easier it is to establish the bond. We know that the bond holds up in increased verbal competence at two years. We know that the bond alters and deflects aggression in animals and humans. Further, we know that in the Kempe (1971) study of over 400 battering parents, 90% were neither psychotic nor psychopathic. They seemed to have serious problems in "mothering," meaning the ability for tender, empathic, individualistic, prompt, and predictable care-giving. And we know that Kempe's findings are not idiosyncratic. As Schwarzbeck INote 4} summarizes the informal observations and research findings of the field, not only is the quality of the abusing mother's relationship with the baby usually observed and described as "inconsistent," "unpredictable," and "unsmooth," but it is also likely that these qualities may have a causative influence. (p. 18) So if we have to make a leap to connect programmatic support for bonding, better parenting as evidenced b y more attachment behaviors, and lessened child abuse, it isn't a very long jump. The accumulation
Journal of Primary Prevention
142
of these findings suggests very strongly that we have found one key to positive parenting and child abuse prevention. As Kennell, Voos, and Klaus {1976} put it in Child Abuse and Neglect: The Family and the
Community: The affectional bonds a mother and father establish with their infant during the first days of life are crucial for his future welfare. When the bonds are solidly established, parents are motivated to learn about their baby's individual requirements and adapt to meet these needs; they are willing to change diapers thousands of times, to respond to the baby's cries in the night, and to provide stimulation appropriate in intensity, timing, and quality. Fully developed specific ties keep parents from striking their baby who has cried for hours night after night--even when they are exhausted and alone. (p. 53)
Program Components Given this knowledge, what are the tasks of the perinatal education and support programmers as these tasks are currently being seen? The following prescriptions are taken in part from the "Joint Position Statement on the Development of Family-Centered Maternity/Newborn Care in Hospitals," prepared by the Interprofessional Task Force on Health Care of Women and Children (1979), and "Wingspread Report: A Community Plan for Preventing Child Abuse," a report of a prevention conference held b y the National Committee for Prevention of Child Abuse (1979}. The first broad category of effort is in the area of preparation of families for the phenomenon of birth. Programmers should provide preparation for childbirth classes taught b y leaders appropriately prepared in medical, physical, and emotional concomitants of childbirth. There should be in these series a mechanism for dovetailing the preparatory classes and material presented with the actual facilities and staff which will attend the mother and child at the time of birth. These classes would begin giving information on child development, parent-child relationships, and skills for coping with the challenges of parenthood. They would also begin building a supportive network among the participants that could continue well beyond the prenatal period. This naturally leads to the preparation of obstetricians' offices and hospital staff. There would be an ongoing educational program that would inform all OB and hospital staff of relevant findings in the fields of parenting, infant psychiatry, and child development such as those listed earlier, to promote a family-centered, supportive atmosphere
Ellen B. Gray
143
throughout the hospital and confinement period. These professionals and their staffs would be taught the earliest warning signals of impaired potential for healthy parent-child relationships. Third would be the family-centered program within the maternity/newborn unit itself. There are numerous structures within which this kind of program could be carried out, but the essential ingredients would be the inclusion of the husband or "supporting other" in the birth process throughout, the maximum participation of the mother in her own delivery tminimal or no anesthesia, overhead mirrors allowing her to see the delivery, arrangements for safe handling of the baby right after birth, and immediate breastfeeding if desired). Included would be: delayed administration of silver nitrate drops to the child's eyes to allow interaction during the baby's first, prolonged alert state; a recovery room set up for a quiet time for mother, father, and baby to get to know each other; and a rooming-in option so that mothers can have their babies for as much time as they wish (within the limits of the newest findings on neonate health and safety), and where the father could have extended visiting privileges. There would be available to the mother during the post-partum period a caring person who would help her learn what her baby can do and how to care for him. Particularly stressed here, too, would be support, education, and activities that would foster the comfort and attachment between parents and child, such as discussion of the uniqueness of the particular child, demonstration of his response capabilities, and techniques to comfort him. The helping person, whether health professional or volunteer, would be trained to be sensitive to and knowledgeable about the stresses childbirth creates for the mother and family and how to deal with them. The final step in this attempt to give parents and baby the best possible start together would be the follow-up program. This would build on the relationship the mother began with the particular nurse or volunteer who offered her support and education during her hospital stay. It might entail a "call-back" arrangement, a pre-set visit appointment, or an agreement to be available when asked. It could be an extended home visitor program including periodic visits to the home following childbirth until the child begins school by a trained home health aide. This aide would provide information to parents on child care, nutrition, and home management and would also carry out routine health checkups on young children. In any case, the individual who was available to the mother would be armed with referral information to a myriad of appropriate medical and supportive services that could head off problems before they became serious barriers to parenting.
144
Journal of Primary Prevention
Demons tration Projects
There are programs operating right now in every part of the country which offer these services singly or in combination. Four demonstration programs selected for funding by the National Center on Child Abuse and Neglect between October, 1979 and December, 1982 are representative strategies for the primary prevention of child abuse, and illustrate an interesting range of approaches. One of these is the Perinatal Positive Parenting Program of the Institute for Family and Child Study at Michigan State University (Grant No. 90-CA-2137, Department of Health, Education, and Welfare, Office of Child Development}. This program aims to take advantage of the mother's receptive period surrounding the birth of the first baby to offer education and support. Information is dispensed by volunteers and through original videotape programs brought right into the mother's hospital room. Videotapes cover what babies can do, "Life with Baby" (feeding, crying, and sleeping}, post-partum depression, time alone for the mother, experiences with the babysitter, sharing child-rearing responsibilities, and single parenthood. The parenting volunteers offer the parent printed material and show the videotapes in steps, guided by the parent's interest and willingness to participate. If the parent has participated in the program throughout the hospital stay, the volunteer asks if she can call in about a week and visit at the home. During the home visit the volunteer offers the parent an opportunity to discuss any questions or concerns she may have or successes she might want to share. The volunteer may demonstrate "infantinteracting activities" with the newborn designed to provide mind and body stimulation, develop concentration, strengthen muscles, increase interaction, foster recognition of mother {or father}, and demonstrate the capabilities of the baby. Two more home visits may be scheduled after the first, if it is felt that they are needed. A newsletter will keep parents informed about the program. It will be published and circulated six times a year and will include information about babies and new exercises and fun activities for parents to engage in with their child. The newsletter will direct parents to supportive resources in the community. One such resource will be a parent support group offered by the Perinatal Positive Parenting Program. In this forum parents will be able to share with other parents their problems, their solutions, their anxieties, and their joy of child rearing. The theory behind the development of these groups is that there is something to be gained
Ellen B. Gray
145
from talking with peers that is different from what a professional or trained volunteer can provide. Specific questions and c o n c e r n s p a r e n t s have for which they want immediate expert advice Can be handled by the remaining component of the Institute for Family and Child S t u d y program: the "warm line." This is a telephone number made available to new parents and staffed by the project. Information on where to go in the community plus specifics on infant development will be given upon request by this service. At Vanderbilt University School of Medicine, a program will demonstrate three variations of increased post-partum contact between parent and child and establish a protocol by which early contact during the first three hours after delivery and extended contact during the first two days following delivery may be implemented in a general hospital setting (Grant No. 90-CA-2138, Department of Health, Education, and Welfare, Office of Child Development}. The intent is to demonstrate that this can be accomplished without undue disruption of staff or any harm to the infant. The project is designed to be evaluated to see if there will be a difference in the number of reported child maltreatment cases between groups, building on Klaus and Kennell's results. In this project, one group of parents will have the amount of contact with their babies that would happen under routine hospital policy. This would most likely consist of a brief glimpse after delivery, no contact for twelve hours, then optional contact between 8:30 a.m. and 1:30 p.m. and between 3:30 p.m. and 6:30 p.m. for the following two or three days. Another group will follow the routine of the comparison group until the b a b y is five hours old, and then a rooming-in arrangement will be followed (8:30 a.m. to 9 p.m. except during the two general visiting hours}. A third group will receive the b a b y for close body contact right after delivery for at least one hour up to a maximum of three hours. For this group, silver nitrate administration to the eyes will be delayed until the b a b y is in nursery. The fourth group will receive the routine of the early contact group until the b a b y is five hours old, and the routine of the extended contact group after that. The three types of early contact were chosen to contrast with the comparison group in order to determine whether increased postpartum contact reduces subsequent child maltreatment and if so, what measurable kind of contact causes the greatest reduction. The original design of this project did not include a claim of enhanced parenting as a benefit of the demonstration. Prior research would suggest that this
146
Journal of Primary Prevention
might happen, however, and perhaps this can be picked up by collaborative evaluation (see "Evaluation" section, below). In a five-country area in Indiana, the Rural Family Support Project takes a system approach to encouraging perinatal support programming {Grant No. 90-CA-2142, Department of Health, Education, and Welfare, Office of Child Development). This demonstration project will recruit, organize, and consult with key community individuals, groups, and agencies with the aim of improving support to families during the perinatal period. In a painstaking, often informal, county-specific way, staff of this project seek to increase hospital awareness, education, and procedures for providing an optimum bonding experience for parents with the newborn; assure comprehensive prenatal instruction to prepare singles and couples for delivery and parenting; put in place a workable system for identifying and appropriately responding to high-risk families; and advocate for parent peer support groups, home visitor programs, and parent education and child development classes. The process consists of establishing a Perinatal Planning Group in each of the five counties, made up of obstetrical department supervisors, directors of nursing, social service and medical consultants: people who can actually bring about change in hospital childbirth procedures as well as plan for it. Simultaneously, a series of in-service training sessions will address the subjects of: procedures for promoting bonding, identifying inappropriate response by parents to newborn, and establishing a supportive response system. Efforts will be made to include the public health system in the training and planning, perhaps expanding their services to include a family-aide home visitor program. The Perinatal Planning Group will tackle the task of improving parental services and expanding them into post-natal and peer support groups. The project will continue to employ the strategy of utilizing established, already-accepted groups to introduce and operate the programs, as this has been most effective in the past in this rural area and offers the highest likelihood of longevity. The "Pride in Parenthood" program in Norfolk, Virgina {Grant No. 90-CA-2139, Department of Health, Education, and Welfare, Office of Child Development), is seeking to provide support and education from a trained family friend in a method similar to the Michigan State program. Norfolk has 10,000 Navy families and therefore a large population of young couples in the inner city who are without family support and who, many times, are not knowledgeable about resources. "Pride in Parenthood" concentrates on these couples by restricting its
Ellen B. Gray
147
program to people residing in the inner city or a military neighborhood, expecting their first child, not living with extended family or having family support readily available, and qualifying for obstetrical care at one of four hospitals or naval clinics. Originally the project also stipulated that the mother should be under twenty-five years of age for inclusion in the program, but has yielded to pressure to include those first-time mothers over twenty-five, as they seemed also to be in the need of the program. The program, chiefly through the efforts of the "Family Friends," will provide to its participants an opportunity for peer interaction and support by establishing groups of first-time parents. It will prepare the participants for childbirth by encouraging them to take Lamaze classes. The program will encourage the father's presence during labor and delivery, and will provide an opportunity for physical contact between parents and newborn to promote bonding. It will provide education in child care, nutrition, and money management through the vehicle of the parents group. And it will link parents up with community resources to provide them with recreation, social contacts, and self-development. The emphasis is on improving the families' chances for successful parenting by giving the parents coping skills and reducing their isolation. Like the Vanderbilt University project, "Pride in Parenthood" is designed so that it can be evaluated. Concurrent to each experimental group, a control group will be selected which will receive no special services. It is predicted that there will be a measurable difference in the parenting ability between the control groups and the groups receiving services.
Evaluation
The National Committee for Prevention of Child Abuse has been given the task of evaluating these perinatal child abuse prevention programs as part of the Collaborative Research of Community and Minority Group Action to Prevent Child Abuse funded by the National Center on Child Abuse and Neglect {Grant No. 90-CA-2048. Department of Health, Education, and Welfare, Office of Child Development}. The perinatal programs make up one of several categories of prevention strategies represented by the eleven projects in this demonstration round. Evaluation of these programs is a challenge because it is in the nature of primary prevention programs that their effectiveness is difficult to measure. It will not be possible to say at the end of the
148
Journal of Primary Prevention
three years for which these programs are funded that they have or have not prevented child abuse. Even in the case of the Vanderbilt University project which intends to obtain the exact statistics of child abuse reports for the four groups in its study, the differences cannot be attributed one hundred percent to the conditions of the study. It is not possible to have control over intervening variables such as positive influences on the families other than the services of the program, outside stresses on the parents, or factors impinging on rate and type of reporting. What we as evaluators c a n do, however, is to develop a design that will capture the differences in these four strategies and the populations they address and to determine interim indicators of potential for parenting that can be measured at strategic points in the passage of parents through these programs. The first task in doing this is to document the components of the interventions so that outcome can be associated with particular efforts: The most discrete intervention, the early and extended contact taking place at Vanderbilt University, is the easiest to document. Michigan State's program is slightly more open-ended, and project effort will have to be strictly specified and correlated with demographic variables. Which films are shown to whom under what circumstances (who else was present, how receptive the participant was to the idea initially}, what use was made of the "warm line" and self-help groups, and particularly, what home visitation follow-up was provided by whose initiative, will need to be spelled out in detail in order to distinguish the effects of the education c o m p o n e n t s from s u p p o r t i v e interventions, volunteer input from peer interaction. A similar documentation process will have to be applied to the Norfolk program, delineating what supportive services were delivered to the participants by the Family Friends, as the program design itself does not limit the helpers, and what they actually end up doing is an important part of the demonstration. The Rural Family Support Program presents a special case, as the intervention takes place at the system level. Although residents of the project's catchment area might conceivably receive as many or more services as participants in any of the other projects, a potentially significant difference is the lack of continuity of service and the variability of service providers in this system-wide project. It will be necessary in addition, then, to document the actual date of inclusion of each advocated service into the routine of a given institution or community in this five-county area. The continuum of services as originally conceived for each of these projects appears in Table 1.
Ellen B. Gray
149
TABLE I Planned Program Components of Perinatal Support Projects
o=
c
°
=
=o
=
*,
INDIVIDUAL INTERVENTIONS Effects of Early and Extended Contact Vanderbilt University
x
Pot@ntial for Positive Parenting Michigan State University Pride in Parenthood Norfolk, Virginia
~)~
X
X
X
X
X
SYSTEM I~[£ERVENTION Rural Family Support Proj eat Columbus, Indiana
X
X
*Depending on the group to which participant is assi ned.
Several outcome measurements will be applied to these projects and correlated with the separate interventions and combinations and with the various characteristics of the participants. One of these instruments, the Neonatal Perception Inventory, or N P I IBroussard, and Hartner 1970}, will be used as a measure of the relationship between mother and infant. Broussard found that newborns perceived negatively by their mothers, i.e., rated below the average b a b y on a number of separate items, had more emotional problems when they were independently assessed at age four. This is thought to represent the mother's inability to idealize the infant. This instrument is
Journal of Primary Prevention
150
designed to be administered on the second post-partum day and again at one month. Because of this it will assess only the services given inhospital and shortly after the mother arrives home. The other established instrument which will be applied to the group is the Adult/Adolescent Parenting Inventory, or A/API (Bavolek, Note 3). This as yet unpublished inventory appears to discriminate between abusive parents and average parents with a high degree of reliability. It will be used as an indicator of risk for abusive behavior. Participants will be compared after service with ratings of themselves before the interventions (when possible), and with controls from the same programs. Both the A/API and the N P I will have to be applied to random samples of the high-volume Vanderbilt and rural Indiana programs. In addition, the Rural Family Support Program will be measured in a multiple base-line time series design b y the use of a questionnaire that picks up characteristics of each delivering mother, her perinatal experiences, all of the services received by her, and her own rating of her confidence as a parent as she leaves the hospital. These indicators and others that are being developed for the evaluation should tell us what dimensions of these programs are crucial and which ones have limited benefit in the short run. Studying whether these assessments of parenting ability hold up over time, whether families showing the most and least potential for family harmony and productive child rearing still sort out the same w a y in five, ten, and fifteen years would, of course, tell us more about the effectiveness of these respective strategies. It is not within the purview of this evaluation to test that. To the extent possible, however, the design will be set up for longitudinal expansion. It is incumbent upon the professions involved in the field of child abuse to get a much firmer idea of what works with whom, and why, in the realm of prevention. This current wave of interest in primary prevention can be developed into effective institutionalized practices of our society, but untested interventions should neither be adopted nor discarded prematurely. Research and evaluation are critical. Perinatal support programming holds much promise as an effective prevention strategy, and we must take a responsible look at it.
Reference Notes 1. Meltzoff, A.N., & Moore, M.K. Neonate imitation: a t e s t of existence and mechanism. Paper presented at the Society for Research in Child Development Meetings, Denver, 1975.
Ellen B. Gray
151
2. McLaughlin, F.J., O'Connor, S., & Deni, R. Infant state and behavior during the first post-partum hour. Paper presented at the International Conference on Infant Studies, Providence, R.I., March 1978. 3. Bavolek, S. Primary prevention of child abuse. Eau Claire, Wis.: University of Wisconsin at Eau Claire, 1980. 4 Schwarzbeck, C. Identification of infants at risk for child neglect: observations and inferences in the examination of the mother-infant dyad. Paper presented at the conference Child abuse: Where do we go from here? Children's Hospital, National Medical Center, Washington, D.C., Conference Proceedings, Feb. 18-20, 1977.
References A community plan for preventing child abuse. A wingspread report. Racine: The Johnson Foundation, 1979. Brazelton, T.B. Neonatal behavioral assessment scale. Clinics in developmental medicine, no. 51. Philadelphia: J. B. Lippincott Co., 1973. Broussard, E.R., & Hartner, M.S. Maternal perception of the neonate as related to development. Child Psychiatry and Human Development, 1970, 1, 16-25. Condon, W.S., & Sander, L.W. Neonate movement is synchronized with adult speech: Interactional participation and language acquisition. Science, 1974, 183, 99-101. Desmond, N.M., Rudolph, A.J., & Phitaksphraiwan, P. The transitional care nursery: A mechanism of a preventive medicine. Pediatric Clinics of North America, 1966, 13, 651. Eisenberg, R.B. Auditory competence in early life: The roots of communicative behavior. Baltimore, Md.: University Park Press, 1976. Emde, R.N., Swedberg, J., & Suzuki, B. Human wakefulness and biological rhythms after birth. Archives of General Psychology, 1975, 32, 780-83. Fantz, R.L., Fagan, J.F., & Miranda, S.B. Early visual selectivity as a function of pattern variables, previous exposure, age from birth and conception, and expected cognitive deficit. In L.B. Cohen & P. Salapatek {Eds.t, Infant perception: From sensation to cognition. New York: Academic Press, !975. Fraiberg, S. The origins of human bonds. Commentary, Dec. 1967, 47-57. Freud, A., & Burlingham, D. Infants without families. London: George Allen & Unwin, 1944. Gregg, C.L., Haffner, M.E., & Korner, A.F. The relative efficacy of vestibular-proprioceptive stimulation and the upright position in enhancing visual pursuit in neonates. Child Development, 1976, 47, 309-14. Interprofessional Task Force on Health Care of Women and Children, Joint position statement on the development of family-centered maternity/newborn care in hospitals. In Selected readings on mother-infant bonding. DHEW Publication No. {OHD) 79-30225, 1979. Kempe, C.H. Pediatric implications of the battered baby syndrome. Archives of Disease in Childhood, Feb. 1971, 46 (245), 23-37. Kennell, J.H., Voos, D., & Klaus, M.H. Parent-infant bonding. In Child abuse and neglect: The family and the community. Cambridge: Ballinger Publishing Co., 1976. Kennell, J.H., Jerauld, R., Wolfe, H., Chesler, D., Kreger, N.C., McAlpine, W., Steffa, M., & Klaus, M.H. Maternal behavior one year after early and extended post-partum contact. Developmental Medicine and Child Neurology, 1974, 16, 172-79. Klaus, M.H., Jerauld, R., Kreger, N.C., McAlpine, W., Steffa, M., & Kennell, J.H. Maternal attachment: Importance of the first post-partum days. New England Journal of Medicine, 1972, 286, 460.
152
Journal of Primary Prevention
Konner, M.J. Aspects of the developmental ethology of a foraging people. In J.N. Burton (Ed.), Ethological studies of child behavior. Cambridge: Cambridge University Press, 1972. Lorenz, K. On aggression. New York: Harcourt Brace and World, 1967. Provence, S., & Lipton, R. Infants in institutions. New York: International Universities Press, Inc., 1962. Ringler, J.H., Kennell, J.H., Jarvella, R., Navojosky, B.J., & Klaus, M.H. Mother-tochild speech: A two-year effect of early postnatal contact. Journal of Pediatrics, 1975, 86, 141-44. Wolff, P.H. The causes, controls and organization of behavior in the neonate. New York: International Universities Press, 1966. Wolff, P.H. The natural history of crying and other vocalizations in early infancy. In B.M. Foss (Ed.), Determinants of infant behavior, Vol. IV. London: Methuen & Company, Ltd., 1969.
Perinatal Support Programs: A Strategy for the Primary Prevention of Child Abuse E L L E N B. G R A Y ABSTRACT." Perinatal support programs are offering new hope for the prevention of child abuse. This article reviews the research stimulating these programs, details the prescribed components of perinatal programs according to the Interprofessional Task Force on Health Care of Women and Children and the National Committee for Prevention of Child Abuse, and discusses four demonstration projects currently being conducted.
An exciting phenomenon is occurring now all over the country: the development of perinatal support programs in child welfare agencies, mental health centers, obstetricians' offices, preparation for childbirth series, hospitals, public health clinics, volunteer agencies, and combinations of these settings. The trend is exciting for a nunber of reasons, not the least of which is the truly multi-disciplinary participation in this movement to provide an optimally close and comforting environment for the parents and child to get to know and fall in love with each other. Doctors, nurses, educators, counselors, social workers, psychologists, and psychiatrists are embracing this implementation of over ten years of research for essentially the same reasons. As one professional put it, "I worked with children with problems for twenty-five years and it seemed that no matter at what point I was getting them, I was too late." It has been said before, b u t it is no less true in the area of child rearing: it is far easier to prevent than to treat. American society approaches the task of bringing up children with considerable ambivalence. We cannot seem to decide how seriously to take the idea of a science of child rearing. From blaming mother for the child's every developing characteristic, we move to recognizing that mother's needs affect the baby and that we therefore must be nonEllen B. Gray is Program Associate for Primary Prevention and Director of the project, "Collaborative Research and Community and Minority Group Action to Prevent Child Abuse," at the National Committee for Prevention of Child Abuse. Reprint requests may be addressed to the author at the National Committee for Prevention of Child Abuse, 332 South Michigan Avenue, #1250, Chicago, Illinois 60604. 0278-095X(82)1300-0138500.95
138
@1982 Human Sciences Press
Ellen B. Gray
139
critical of her. From a heavy-handed dissemination of new research indicating that certain modern conveniences--anesthesia, bottles, formula--are not as good for baby as the old-fashioned ways, we shift back to a recognition of the social, financial, and political stresses women suffer and a consequent letting up on mothers. And now to the latest discoveries that even in the earliest moments of life, the motherinfant relationship is critical. There is sometimes only a fine line between putting into practice the exciting up-to-the-minute discoveries of researchers in the field, and putting excessive and damaging pressure on the parents. That is why this newest piece of child development, this whole notion of "bonding" and "attachment" offers such hope. It is the positive nature and the fundamental reciprocity of the concept that is so different and encouraging. It is the idea that what is best for the baby in this instance is the same thing that makes child rearing easiest and most enjoyable for the mother. We are thinking now that perhaps this simple but elusive process of human attachment will prevent the eventuality of mother's and child's needs being constantly at odds, a situation common in child abuse cases; and we are acting to promote this attachment.
Research Although this program emphasis is relatively new, it is grounded in more than a decade of research. One thrust of this research involves the capabilities of the newborn. A number of studies, for example, have debunked the myth that newborns cannot see. On the contrary, Brazelton {1973}, Fantz, Fagan, and Miranda {1975), and Wolff {1966} have shown that immediately after birth, humans can focus, track, and discriminate a face-like pattern. Meltzoff and Moore {Note 1) found that for a brief period of time after birth, the infant can imitate facial expressions presented to him. Eisenberg (1976} has shown that infants prefer human voices and speech patterns to less meaningful noises, and Condon and Sander {1974) showed that the infants move in synchrony with these speech patterns. The Brazelton demonstrations {1973} show that the infant has an amazing amount of control over his own "state" and manages the environment in this way. He can shut out disturbing stimuli and can regulate his alertness to attend to people and objects. Another category of research leading to perinatal support programming discloses the automatic reciprocal responses between mother and baby. Irritable infant crying elicits a response from
140
Journal of Primary Prevention
mother that was measured by Gregg, Haffner, and Korner 11976). Mother picks the child up and rests him at her shoulder. This in turn quiets him and produces visual alertness, which is pleasing to the mother. Emde, Swedberg, and Suzuki {1975} and McLaughlin, O'Connor, and Deni {Note 2) showed a significantly prolonged alert state in the first hour post-partum {provided silver nitrate drops to the eyes are delayed}. Separate studies in the United States {Wolff, 1969} and Africa (Konner, 1972) have shown that the pain cry brings forth particularly prompt and concerned response by adults, and although we don't need research to know that if an infant smiles, we smile back, there is now scientific backup for this, also. Building on these findings of readiness for interaction of mother and child right after birth has been the discovery that this is the optimal and critical time for the attachment process to begin, and that sucessful mother-child bonding may play a vital role in preventing future parenting disturbances. Dr. Marshall Klaus and his associates i1972} of Case Western Reserve University School of Medicine studied a group of twenty-eight women who had just had their first babies, normal healthy infants. Half of the group received the routine contact with their babies which was allowed by most hospitals--a glimpse of the child immediately after birth, another short contact six to twelve hours later, and then every four hours, a twenty- to thirty-minute visit. The other half of the group had an opportunity for early contact consisting of receiving the baby, nude, with a heat panel for an hour during the first three hours after birth and five additional hours per afternoon for the three days following delivery. The mothers were observed feeding their infants, were interviewed, and had physical examinations on three occasions after three months. The mothers who received only routine contact were still "distant" from their infants at that time, displaying significantly less attachment behavior {looking at and smiling at the baby, holding and caressing him} than the early contact group. This apparent bonding may be attributable to the "maternal-sensitive" period that Klaus, Jerauld, Kreger, McAlpine, Steffa, and Kennell {1972} and others have postulated. It may be due also to the heightened state of alertness and responsiveness of the baby that Desmond, Rudolph, and Phitaksphraiwan (1966} found to exist in the first hour of life. In a latter study, Kennell, Jerauld, Wolfe, Chesler, Kreger, McAlpine, Steffa, and Klaus {1974} showed that the differences in attachment behavior between mothers having early and extended contact with their newborns and mothers having only routine contact were strikingly observable at one year. Ringler, Kennel, Jarvella, Navojosky, and
Ellen B. Gray
141
Klaus (1975} showed that even linguistic behavior of children can be affected b y immediate post-natal contact. Mothers were shown to engage in much more sophisticated verbal interactions with their twoyear-olds if they had had an opportunity for such contact. Even the lower animals provide data for the empirical underpinnings of current perinatal support programming. Ethologist Konrad Lorenz (1967} spells out the phylogenetic relationship between aggression and love. Extensive studies led him to conclude that within every one of those species which have developed "the bond" {the enduring ties that unite members} there are biological mechanisms for inhibiting or transforming aggression in the service of love. Professor and child analyst Selma Fraiberg t1967) establishes the parallel with humans by reminding us of the institution studies of Freud and Burlingham {1944) and Provence and Lipton {1962} that showed in the ill-mothered children, impulsivity, intolerance for frustration, rages and tantrums far out of proportion to "normal" children their age. "Where there are no human bonds," she writes, "there is no motive for redirection, for the regulation and control of aggressive urges." Fraiberg is talking of the "diseases of non-attachment" and of the hollow men and women who result from this lack in infancy. Child abuse clearly falls within the purview of these aggression diseases, and child abusers are more often than not the hollow men and women she describes. If we believe all of this evidence, we know that babies are ready to establish that love bond at birth. We know that the earlier the attachment process begins and the more time that mother and baby spend together during this crucial period, the easier it is to establish the bond. We know that the bond holds up in increased verbal competence at two years. We know that the bond alters and deflects aggression in animals and humans. Further, we know that in the Kempe (1971) study of over 400 battering parents, 90% were neither psychotic nor psychopathic. They seemed to have serious problems in "mothering," meaning the ability for tender, empathic, individualistic, prompt, and predictable care-giving. And we know that Kempe's findings are not idiosyncratic. As Schwarzbeck INote 4} summarizes the informal observations and research findings of the field, not only is the quality of the abusing mother's relationship with the baby usually observed and described as "inconsistent," "unpredictable," and "unsmooth," but it is also likely that these qualities may have a causative influence. (p. 18) So if we have to make a leap to connect programmatic support for bonding, better parenting as evidenced b y more attachment behaviors, and lessened child abuse, it isn't a very long jump. The accumulation
Journal of Primary Prevention
142
of these findings suggests very strongly that we have found one key to positive parenting and child abuse prevention. As Kennell, Voos, and Klaus {1976} put it in Child Abuse and Neglect: The Family and the
Community: The affectional bonds a mother and father establish with their infant during the first days of life are crucial for his future welfare. When the bonds are solidly established, parents are motivated to learn about their baby's individual requirements and adapt to meet these needs; they are willing to change diapers thousands of times, to respond to the baby's cries in the night, and to provide stimulation appropriate in intensity, timing, and quality. Fully developed specific ties keep parents from striking their baby who has cried for hours night after night--even when they are exhausted and alone. (p. 53)
Program Components Given this knowledge, what are the tasks of the perinatal education and support programmers as these tasks are currently being seen? The following prescriptions are taken in part from the "Joint Position Statement on the Development of Family-Centered Maternity/Newborn Care in Hospitals," prepared by the Interprofessional Task Force on Health Care of Women and Children (1979), and "Wingspread Report: A Community Plan for Preventing Child Abuse," a report of a prevention conference held b y the National Committee for Prevention of Child Abuse (1979}. The first broad category of effort is in the area of preparation of families for the phenomenon of birth. Programmers should provide preparation for childbirth classes taught b y leaders appropriately prepared in medical, physical, and emotional concomitants of childbirth. There should be in these series a mechanism for dovetailing the preparatory classes and material presented with the actual facilities and staff which will attend the mother and child at the time of birth. These classes would begin giving information on child development, parent-child relationships, and skills for coping with the challenges of parenthood. They would also begin building a supportive network among the participants that could continue well beyond the prenatal period. This naturally leads to the preparation of obstetricians' offices and hospital staff. There would be an ongoing educational program that would inform all OB and hospital staff of relevant findings in the fields of parenting, infant psychiatry, and child development such as those listed earlier, to promote a family-centered, supportive atmosphere
Ellen B. Gray
143
throughout the hospital and confinement period. These professionals and their staffs would be taught the earliest warning signals of impaired potential for healthy parent-child relationships. Third would be the family-centered program within the maternity/newborn unit itself. There are numerous structures within which this kind of program could be carried out, but the essential ingredients would be the inclusion of the husband or "supporting other" in the birth process throughout, the maximum participation of the mother in her own delivery tminimal or no anesthesia, overhead mirrors allowing her to see the delivery, arrangements for safe handling of the baby right after birth, and immediate breastfeeding if desired). Included would be: delayed administration of silver nitrate drops to the child's eyes to allow interaction during the baby's first, prolonged alert state; a recovery room set up for a quiet time for mother, father, and baby to get to know each other; and a rooming-in option so that mothers can have their babies for as much time as they wish (within the limits of the newest findings on neonate health and safety), and where the father could have extended visiting privileges. There would be available to the mother during the post-partum period a caring person who would help her learn what her baby can do and how to care for him. Particularly stressed here, too, would be support, education, and activities that would foster the comfort and attachment between parents and child, such as discussion of the uniqueness of the particular child, demonstration of his response capabilities, and techniques to comfort him. The helping person, whether health professional or volunteer, would be trained to be sensitive to and knowledgeable about the stresses childbirth creates for the mother and family and how to deal with them. The final step in this attempt to give parents and baby the best possible start together would be the follow-up program. This would build on the relationship the mother began with the particular nurse or volunteer who offered her support and education during her hospital stay. It might entail a "call-back" arrangement, a pre-set visit appointment, or an agreement to be available when asked. It could be an extended home visitor program including periodic visits to the home following childbirth until the child begins school by a trained home health aide. This aide would provide information to parents on child care, nutrition, and home management and would also carry out routine health checkups on young children. In any case, the individual who was available to the mother would be armed with referral information to a myriad of appropriate medical and supportive services that could head off problems before they became serious barriers to parenting.
144
Journal of Primary Prevention
Demons tration Projects
There are programs operating right now in every part of the country which offer these services singly or in combination. Four demonstration programs selected for funding by the National Center on Child Abuse and Neglect between October, 1979 and December, 1982 are representative strategies for the primary prevention of child abuse, and illustrate an interesting range of approaches. One of these is the Perinatal Positive Parenting Program of the Institute for Family and Child Study at Michigan State University (Grant No. 90-CA-2137, Department of Health, Education, and Welfare, Office of Child Development}. This program aims to take advantage of the mother's receptive period surrounding the birth of the first baby to offer education and support. Information is dispensed by volunteers and through original videotape programs brought right into the mother's hospital room. Videotapes cover what babies can do, "Life with Baby" (feeding, crying, and sleeping}, post-partum depression, time alone for the mother, experiences with the babysitter, sharing child-rearing responsibilities, and single parenthood. The parenting volunteers offer the parent printed material and show the videotapes in steps, guided by the parent's interest and willingness to participate. If the parent has participated in the program throughout the hospital stay, the volunteer asks if she can call in about a week and visit at the home. During the home visit the volunteer offers the parent an opportunity to discuss any questions or concerns she may have or successes she might want to share. The volunteer may demonstrate "infantinteracting activities" with the newborn designed to provide mind and body stimulation, develop concentration, strengthen muscles, increase interaction, foster recognition of mother {or father}, and demonstrate the capabilities of the baby. Two more home visits may be scheduled after the first, if it is felt that they are needed. A newsletter will keep parents informed about the program. It will be published and circulated six times a year and will include information about babies and new exercises and fun activities for parents to engage in with their child. The newsletter will direct parents to supportive resources in the community. One such resource will be a parent support group offered by the Perinatal Positive Parenting Program. In this forum parents will be able to share with other parents their problems, their solutions, their anxieties, and their joy of child rearing. The theory behind the development of these groups is that there is something to be gained
Ellen B. Gray
145
from talking with peers that is different from what a professional or trained volunteer can provide. Specific questions and c o n c e r n s p a r e n t s have for which they want immediate expert advice Can be handled by the remaining component of the Institute for Family and Child S t u d y program: the "warm line." This is a telephone number made available to new parents and staffed by the project. Information on where to go in the community plus specifics on infant development will be given upon request by this service. At Vanderbilt University School of Medicine, a program will demonstrate three variations of increased post-partum contact between parent and child and establish a protocol by which early contact during the first three hours after delivery and extended contact during the first two days following delivery may be implemented in a general hospital setting (Grant No. 90-CA-2138, Department of Health, Education, and Welfare, Office of Child Development}. The intent is to demonstrate that this can be accomplished without undue disruption of staff or any harm to the infant. The project is designed to be evaluated to see if there will be a difference in the number of reported child maltreatment cases between groups, building on Klaus and Kennell's results. In this project, one group of parents will have the amount of contact with their babies that would happen under routine hospital policy. This would most likely consist of a brief glimpse after delivery, no contact for twelve hours, then optional contact between 8:30 a.m. and 1:30 p.m. and between 3:30 p.m. and 6:30 p.m. for the following two or three days. Another group will follow the routine of the comparison group until the b a b y is five hours old, and then a rooming-in arrangement will be followed (8:30 a.m. to 9 p.m. except during the two general visiting hours}. A third group will receive the b a b y for close body contact right after delivery for at least one hour up to a maximum of three hours. For this group, silver nitrate administration to the eyes will be delayed until the b a b y is in nursery. The fourth group will receive the routine of the early contact group until the b a b y is five hours old, and the routine of the extended contact group after that. The three types of early contact were chosen to contrast with the comparison group in order to determine whether increased postpartum contact reduces subsequent child maltreatment and if so, what measurable kind of contact causes the greatest reduction. The original design of this project did not include a claim of enhanced parenting as a benefit of the demonstration. Prior research would suggest that this
146
Journal of Primary Prevention
might happen, however, and perhaps this can be picked up by collaborative evaluation (see "Evaluation" section, below). In a five-country area in Indiana, the Rural Family Support Project takes a system approach to encouraging perinatal support programming {Grant No. 90-CA-2142, Department of Health, Education, and Welfare, Office of Child Development). This demonstration project will recruit, organize, and consult with key community individuals, groups, and agencies with the aim of improving support to families during the perinatal period. In a painstaking, often informal, county-specific way, staff of this project seek to increase hospital awareness, education, and procedures for providing an optimum bonding experience for parents with the newborn; assure comprehensive prenatal instruction to prepare singles and couples for delivery and parenting; put in place a workable system for identifying and appropriately responding to high-risk families; and advocate for parent peer support groups, home visitor programs, and parent education and child development classes. The process consists of establishing a Perinatal Planning Group in each of the five counties, made up of obstetrical department supervisors, directors of nursing, social service and medical consultants: people who can actually bring about change in hospital childbirth procedures as well as plan for it. Simultaneously, a series of in-service training sessions will address the subjects of: procedures for promoting bonding, identifying inappropriate response by parents to newborn, and establishing a supportive response system. Efforts will be made to include the public health system in the training and planning, perhaps expanding their services to include a family-aide home visitor program. The Perinatal Planning Group will tackle the task of improving parental services and expanding them into post-natal and peer support groups. The project will continue to employ the strategy of utilizing established, already-accepted groups to introduce and operate the programs, as this has been most effective in the past in this rural area and offers the highest likelihood of longevity. The "Pride in Parenthood" program in Norfolk, Virgina {Grant No. 90-CA-2139, Department of Health, Education, and Welfare, Office of Child Development), is seeking to provide support and education from a trained family friend in a method similar to the Michigan State program. Norfolk has 10,000 Navy families and therefore a large population of young couples in the inner city who are without family support and who, many times, are not knowledgeable about resources. "Pride in Parenthood" concentrates on these couples by restricting its
Ellen B. Gray
147
program to people residing in the inner city or a military neighborhood, expecting their first child, not living with extended family or having family support readily available, and qualifying for obstetrical care at one of four hospitals or naval clinics. Originally the project also stipulated that the mother should be under twenty-five years of age for inclusion in the program, but has yielded to pressure to include those first-time mothers over twenty-five, as they seemed also to be in the need of the program. The program, chiefly through the efforts of the "Family Friends," will provide to its participants an opportunity for peer interaction and support by establishing groups of first-time parents. It will prepare the participants for childbirth by encouraging them to take Lamaze classes. The program will encourage the father's presence during labor and delivery, and will provide an opportunity for physical contact between parents and newborn to promote bonding. It will provide education in child care, nutrition, and money management through the vehicle of the parents group. And it will link parents up with community resources to provide them with recreation, social contacts, and self-development. The emphasis is on improving the families' chances for successful parenting by giving the parents coping skills and reducing their isolation. Like the Vanderbilt University project, "Pride in Parenthood" is designed so that it can be evaluated. Concurrent to each experimental group, a control group will be selected which will receive no special services. It is predicted that there will be a measurable difference in the parenting ability between the control groups and the groups receiving services.
Evaluation
The National Committee for Prevention of Child Abuse has been given the task of evaluating these perinatal child abuse prevention programs as part of the Collaborative Research of Community and Minority Group Action to Prevent Child Abuse funded by the National Center on Child Abuse and Neglect {Grant No. 90-CA-2048. Department of Health, Education, and Welfare, Office of Child Development}. The perinatal programs make up one of several categories of prevention strategies represented by the eleven projects in this demonstration round. Evaluation of these programs is a challenge because it is in the nature of primary prevention programs that their effectiveness is difficult to measure. It will not be possible to say at the end of the
148
Journal of Primary Prevention
three years for which these programs are funded that they have or have not prevented child abuse. Even in the case of the Vanderbilt University project which intends to obtain the exact statistics of child abuse reports for the four groups in its study, the differences cannot be attributed one hundred percent to the conditions of the study. It is not possible to have control over intervening variables such as positive influences on the families other than the services of the program, outside stresses on the parents, or factors impinging on rate and type of reporting. What we as evaluators c a n do, however, is to develop a design that will capture the differences in these four strategies and the populations they address and to determine interim indicators of potential for parenting that can be measured at strategic points in the passage of parents through these programs. The first task in doing this is to document the components of the interventions so that outcome can be associated with particular efforts: The most discrete intervention, the early and extended contact taking place at Vanderbilt University, is the easiest to document. Michigan State's program is slightly more open-ended, and project effort will have to be strictly specified and correlated with demographic variables. Which films are shown to whom under what circumstances (who else was present, how receptive the participant was to the idea initially}, what use was made of the "warm line" and self-help groups, and particularly, what home visitation follow-up was provided by whose initiative, will need to be spelled out in detail in order to distinguish the effects of the education c o m p o n e n t s from s u p p o r t i v e interventions, volunteer input from peer interaction. A similar documentation process will have to be applied to the Norfolk program, delineating what supportive services were delivered to the participants by the Family Friends, as the program design itself does not limit the helpers, and what they actually end up doing is an important part of the demonstration. The Rural Family Support Program presents a special case, as the intervention takes place at the system level. Although residents of the project's catchment area might conceivably receive as many or more services as participants in any of the other projects, a potentially significant difference is the lack of continuity of service and the variability of service providers in this system-wide project. It will be necessary in addition, then, to document the actual date of inclusion of each advocated service into the routine of a given institution or community in this five-county area. The continuum of services as originally conceived for each of these projects appears in Table 1.
Ellen B. Gray
149
TABLE I Planned Program Components of Perinatal Support Projects
o=
c
°
=
=o
=
*,
INDIVIDUAL INTERVENTIONS Effects of Early and Extended Contact Vanderbilt University
x
Pot@ntial for Positive Parenting Michigan State University Pride in Parenthood Norfolk, Virginia
~)~
X
X
X
X
X
SYSTEM I~[£ERVENTION Rural Family Support Proj eat Columbus, Indiana
X
X
*Depending on the group to which participant is assi ned.
Several outcome measurements will be applied to these projects and correlated with the separate interventions and combinations and with the various characteristics of the participants. One of these instruments, the Neonatal Perception Inventory, or N P I IBroussard, and Hartner 1970}, will be used as a measure of the relationship between mother and infant. Broussard found that newborns perceived negatively by their mothers, i.e., rated below the average b a b y on a number of separate items, had more emotional problems when they were independently assessed at age four. This is thought to represent the mother's inability to idealize the infant. This instrument is
Journal of Primary Prevention
150
designed to be administered on the second post-partum day and again at one month. Because of this it will assess only the services given inhospital and shortly after the mother arrives home. The other established instrument which will be applied to the group is the Adult/Adolescent Parenting Inventory, or A/API (Bavolek, Note 3). This as yet unpublished inventory appears to discriminate between abusive parents and average parents with a high degree of reliability. It will be used as an indicator of risk for abusive behavior. Participants will be compared after service with ratings of themselves before the interventions (when possible), and with controls from the same programs. Both the A/API and the N P I will have to be applied to random samples of the high-volume Vanderbilt and rural Indiana programs. In addition, the Rural Family Support Program will be measured in a multiple base-line time series design b y the use of a questionnaire that picks up characteristics of each delivering mother, her perinatal experiences, all of the services received by her, and her own rating of her confidence as a parent as she leaves the hospital. These indicators and others that are being developed for the evaluation should tell us what dimensions of these programs are crucial and which ones have limited benefit in the short run. Studying whether these assessments of parenting ability hold up over time, whether families showing the most and least potential for family harmony and productive child rearing still sort out the same w a y in five, ten, and fifteen years would, of course, tell us more about the effectiveness of these respective strategies. It is not within the purview of this evaluation to test that. To the extent possible, however, the design will be set up for longitudinal expansion. It is incumbent upon the professions involved in the field of child abuse to get a much firmer idea of what works with whom, and why, in the realm of prevention. This current wave of interest in primary prevention can be developed into effective institutionalized practices of our society, but untested interventions should neither be adopted nor discarded prematurely. Research and evaluation are critical. Perinatal support programming holds much promise as an effective prevention strategy, and we must take a responsible look at it.
Reference Notes 1. Meltzoff, A.N., & Moore, M.K. Neonate imitation: a t e s t of existence and mechanism. Paper presented at the Society for Research in Child Development Meetings, Denver, 1975.
Ellen B. Gray
151
2. McLaughlin, F.J., O'Connor, S., & Deni, R. Infant state and behavior during the first post-partum hour. Paper presented at the International Conference on Infant Studies, Providence, R.I., March 1978. 3. Bavolek, S. Primary prevention of child abuse. Eau Claire, Wis.: University of Wisconsin at Eau Claire, 1980. 4 Schwarzbeck, C. Identification of infants at risk for child neglect: observations and inferences in the examination of the mother-infant dyad. Paper presented at the conference Child abuse: Where do we go from here? Children's Hospital, National Medical Center, Washington, D.C., Conference Proceedings, Feb. 18-20, 1977.
References A community plan for preventing child abuse. A wingspread report. Racine: The Johnson Foundation, 1979. Brazelton, T.B. Neonatal behavioral assessment scale. Clinics in developmental medicine, no. 51. Philadelphia: J. B. Lippincott Co., 1973. Broussard, E.R., & Hartner, M.S. Maternal perception of the neonate as related to development. Child Psychiatry and Human Development, 1970, 1, 16-25. Condon, W.S., & Sander, L.W. Neonate movement is synchronized with adult speech: Interactional participation and language acquisition. Science, 1974, 183, 99-101. Desmond, N.M., Rudolph, A.J., & Phitaksphraiwan, P. The transitional care nursery: A mechanism of a preventive medicine. Pediatric Clinics of North America, 1966, 13, 651. Eisenberg, R.B. Auditory competence in early life: The roots of communicative behavior. Baltimore, Md.: University Park Press, 1976. Emde, R.N., Swedberg, J., & Suzuki, B. Human wakefulness and biological rhythms after birth. Archives of General Psychology, 1975, 32, 780-83. Fantz, R.L., Fagan, J.F., & Miranda, S.B. Early visual selectivity as a function of pattern variables, previous exposure, age from birth and conception, and expected cognitive deficit. In L.B. Cohen & P. Salapatek {Eds.t, Infant perception: From sensation to cognition. New York: Academic Press, !975. Fraiberg, S. The origins of human bonds. Commentary, Dec. 1967, 47-57. Freud, A., & Burlingham, D. Infants without families. London: George Allen & Unwin, 1944. Gregg, C.L., Haffner, M.E., & Korner, A.F. The relative efficacy of vestibular-proprioceptive stimulation and the upright position in enhancing visual pursuit in neonates. Child Development, 1976, 47, 309-14. Interprofessional Task Force on Health Care of Women and Children, Joint position statement on the development of family-centered maternity/newborn care in hospitals. In Selected readings on mother-infant bonding. DHEW Publication No. {OHD) 79-30225, 1979. Kempe, C.H. Pediatric implications of the battered baby syndrome. Archives of Disease in Childhood, Feb. 1971, 46 (245), 23-37. Kennell, J.H., Voos, D., & Klaus, M.H. Parent-infant bonding. In Child abuse and neglect: The family and the community. Cambridge: Ballinger Publishing Co., 1976. Kennell, J.H., Jerauld, R., Wolfe, H., Chesler, D., Kreger, N.C., McAlpine, W., Steffa, M., & Klaus, M.H. Maternal behavior one year after early and extended post-partum contact. Developmental Medicine and Child Neurology, 1974, 16, 172-79. Klaus, M.H., Jerauld, R., Kreger, N.C., McAlpine, W., Steffa, M., & Kennell, J.H. Maternal attachment: Importance of the first post-partum days. New England Journal of Medicine, 1972, 286, 460.
152
Journal of Primary Prevention
Konner, M.J. Aspects of the developmental ethology of a foraging people. In J.N. Burton (Ed.), Ethological studies of child behavior. Cambridge: Cambridge University Press, 1972. Lorenz, K. On aggression. New York: Harcourt Brace and World, 1967. Provence, S., & Lipton, R. Infants in institutions. New York: International Universities Press, Inc., 1962. Ringler, J.H., Kennell, J.H., Jarvella, R., Navojosky, B.J., & Klaus, M.H. Mother-tochild speech: A two-year effect of early postnatal contact. Journal of Pediatrics, 1975, 86, 141-44. Wolff, P.H. The causes, controls and organization of behavior in the neonate. New York: International Universities Press, 1966. Wolff, P.H. The natural history of crying and other vocalizations in early infancy. In B.M. Foss (Ed.), Determinants of infant behavior, Vol. IV. London: Methuen & Company, Ltd., 1969.
