Prospective Longitudinal Study of Beliefs, Sleeping Arrangements, Feeding Practices and Attachment of At-risk Teen Moms

1. Prospective Longitudinal Study of Beliefs, Sleeping Arrangements, Feeding Practices and Attachment of At-risk Teen Moms(implications for SIDS risks and thwarting abuse and neglect) James J. McKenna University of Notre Dame Research Funded by HD 39456-01 JMcKenna, JBorkowski, CRaney, SRaney, JCarta, Swarren (PI’s)

3. Study Design Study primarily involving developmental psychologists Large, longitudinal study representing four different parts of the U.S. using ethnically-matched samples of adolescent, low-education adult and high-education adult first-time mothers. (High-ed qualification based on 2 years of college education) Goal is to identify mothers at risk of neglecting their children in order to design intervention strategies that target the identified parenting deficits. Study primarily involving developmental psychologists Large, longitudinal study representing four different parts of the U.S. using ethnically-matched samples of adolescent, low-education adult and high-education adult first-time mothers. (High-ed qualification based on 2 years of college education) Goal is to identify mothers at risk of neglecting their children in order to design intervention strategies that target the identified parenting deficits.

5. General Research Questions Do adolescent mothers differ from adult mothers in various dimensions of neglectful-risky and/or positive nighttime parenting? Can we predict any “outcomes” local (sleep environment) or long term..based on age, depression scores, history of abuse etc? What is the relationship between daytime and nighttime parenting? What does nighttime parental neglect look like? What is the relationship between sleep and feeding behaviors and child outcomes at 1, 2 and 3 years? --mother IS the environment (Sarah Blaffer Hrdy, Mother Nature) --DYAD is the unit of study; human parental care is synonymous with phsyiological regulation --choice of parenting behavior has physiological implications for the child. Choice of something like sleeping arrangement affects feeding, sleep position, thermoreg, sleep architecture, microenvironment, breathing patterns, emotional/affectionate interactions, crying duration and frequency, etc. --there is no such thing as a baby, there is a baby and someone --behavior and physiology affect each other. Hidden regulatory mechanisms. Behaviors function as part of an adaptive package; we know from past experience that when behaviors are disarticulated from this behavioral complex, negative outcomes can be the result (ex: solitary sleeping, prone positioning, and SIDS).--mother IS the environment (Sarah Blaffer Hrdy, Mother Nature) --DYAD is the unit of study; human parental care is synonymous with phsyiological regulation --choice of parenting behavior has physiological implications for the child. Choice of something like sleeping arrangement affects feeding, sleep position, thermoreg, sleep architecture, microenvironment, breathing patterns, emotional/affectionate interactions, crying duration and frequency, etc. --there is no such thing as a baby, there is a baby and someone --behavior and physiology affect each other. Hidden regulatory mechanisms. Behaviors function as part of an adaptive package; we know from past experience that when behaviors are disarticulated from this behavioral complex, negative outcomes can be the result (ex: solitary sleeping, prone positioning, and SIDS).

7. Assessment of Mother and Children Across a 3 Year Period

8. Child Across Three Year Period

9. Key Questions What is neglect? How is it differentiated from insensitive parenting or sub-group (cultural) differences? Are there distinct dimensions of psycho-social neglect? Do adolescent mother differ from adult mothers in various dimensions of “neglectful” parenting? Does neglect play a unique role in repdicting child development in multiple domains?

10. Sleep Study Design Sleep lab study only being done at the South Bend/Notre Dame site. Sleep lab visits coincide with the home visits that are conducted at 4 and 8 months, particularly because we do some naturalistic observation in the home. This enables some comparison between direct observation measures of daytime and nighttime parenting.Sleep lab study only being done at the South Bend/Notre Dame site. Sleep lab visits coincide with the home visits that are conducted at 4 and 8 months, particularly because we do some naturalistic observation in the home. This enables some comparison between direct observation measures of daytime and nighttime parenting.

11. The study is compiling a wealth of data using multiple measures and multiple informants across the first three years of the child’s life. The parenting measures are collected both in the laboratory and in the home, and one unique component of this study is that we also give the participants cell phones to allow periods of intensive data collection with minimal disruption to the mothers’ lives. The data discussed in this presentation will pull together information from a variety of these sources. The study is compiling a wealth of data using multiple measures and multiple informants across the first three years of the child’s life. The parenting measures are collected both in the laboratory and in the home, and one unique component of this study is that we also give the participants cell phones to allow periods of intensive data collection with minimal disruption to the mothers’ lives. The data discussed in this presentation will pull together information from a variety of these sources.

12. South Bend Sample Demographics 55 adolescent and 31 high-education adult primiparas Mean age at childbirth 16.6 years for adolescents and 26.7 years for adults 56% Caucasian, 31% African-American, 3% Latina, 10% other/multi-ethnic 64% female infants Recruited from primary care facilities, WIC offices and one school-age mothers program at a local high school. The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the health of low-income women, infants, & children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. Of these, 15 adolescent and 10 adult high-education mothers have participated in the sleep lab portion of the study thus far. These are the racial categories endorsed by the mothers.Recruited from primary care facilities, WIC offices and one school-age mothers program at a local high school. The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the health of low-income women, infants, & children up to age 5 who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. Of these, 15 adolescent and 10 adult high-education mothers have participated in the sleep lab portion of the study thus far. These are the racial categories endorsed by the mothers.

13. Prenatal Self-Report Measures Adolescent Adult Depression No depression 34% 38% Mild 28% 25% Moderate 25% 33% Severe 13% 4% Substance Use Alcohol 14% 27% Cigarettes 24% 9% Drugs 12% 0% Teen mothers more likely to be severely depressed. Adult mothers exhibiting somewhat higher depression scores. We will also be assessing depression at future assessment points, so it will be interesting to see if this trend remains stable or changes over time. Substance use question is given during the last trimester of pregnancy and asks about any substances used during the last six months. Adult mothers slightly more likely to consume alcohol prenatally, but teens are reporting a much higher rate of cigarette and drug use prenatally. Teen mothers more likely to be severely depressed. Adult mothers exhibiting somewhat higher depression scores. We will also be assessing depression at future assessment points, so it will be interesting to see if this trend remains stable or changes over time. Substance use question is given during the last trimester of pregnancy and asks about any substances used during the last six months. Adult mothers slightly more likely to consume alcohol prenatally, but teens are reporting a much higher rate of cigarette and drug use prenatally.

14. Sleep Lab Component Are there continuities between the nature and quality of day and nighttime caregiving patterns? As regards nighttime caregiving -parenting practices, is there congruence between what teen-adolescent and adult high resource moms say (beliefs) and what they do? Where or from whom do the beliefs come from? Adolescent teen moms are hypothesized to exhibit more high risk nighttime care practices, experience less attachment to their infants than high resource moms, be less aware of what is risky, and exhibit more depression, leading to lower developmental including social, cognitive and psychological outcomes for their infants.

15. University of Notre Dame Mother-Baby Behavioral Sleep Laboratory Sleep lab designed to look as much like a home environment as possible Mothers instructed to maintain normal routines as much as possible and are allowed to perform all caregiver interventions at will And lab allows for almost any possible sleeping arrangement that the mothers choose, including having the infant sleep in a crib in a separate room, in a bedside bassinet in the same room, or in bed with mom. Lab also has a lounge with television, movies, snacks and drinks and we film some of our most interesting interactions here. This is a new component of the current study which allows us to capture mother-baby interactions in the pre-sleep period, which has not been done before. Sleep lab designed to look as much like a home environment as possible Mothers instructed to maintain normal routines as much as possible and are allowed to perform all caregiver interventions at will And lab allows for almost any possible sleeping arrangement that the mothers choose, including having the infant sleep in a crib in a separate room, in a bedside bassinet in the same room, or in bed with mom. Lab also has a lounge with television, movies, snacks and drinks and we film some of our most interesting interactions here. This is a new component of the current study which allows us to capture mother-baby interactions in the pre-sleep period, which has not been done before.

16. There are interesting group differences between teens and adults. We have a relatively small sample thus far so most of the differences are only approaching significance at this point, but they’re suggestive of interesting areas to look at as the study progresses. The following case studies chosen to highlight the extremes of parenting. By examining these extremes, we are able to formulate more specific research questions to guide the next phase of data collection. There are interesting group differences between teens and adults. We have a relatively small sample thus far so most of the differences are only approaching significance at this point, but they’re suggestive of interesting areas to look at as the study progresses. The following case studies chosen to highlight the extremes of parenting. By examining these extremes, we are able to formulate more specific research questions to guide the next phase of data collection.

17. Noldus Computer -Based Video Scoring and Coding Techniques: 8 Behavioral Classes Infant sleep state Mother sleep state Infant sleep proximity Infant sleep position Risks to infant Breathing, overheating, falling, entrapment, feeding, punitive, rejection Infant crying Feeding breast feeding, bottle feeding, spoon feeding, infant attempt feed, mother attempt feed, not feeding, appears to feed, no feed; Sleep location Crib separate room, bassinette same room, alone on adult bed, in bed with mom, sofa, floor, carrier, other,

18. Noldus Computer -Based Classes: 9 Behavioral Modifiers (of the Classes) Class 1: Relative distances Touching/physical contact,within arms reach, beyond mothers arm reach; Class 2: Sleep body orientation (facing away, facing toward, neutral); Class 3: Infant head position..baby’s eyes level with mom face--shoulder? breast? waist? Class 4: Initiator (Mom or Infant; Class 5: Risk Material/Object Blanket, pillow, toys, mothers arm, leg, clothing, food or liquid; Class 6: Secondary Risk: breathing, overheating, falling, entrapment,punitive, rejection; Class 7: Response Mother responds, mother does not respond

19. What is scored per category or class: Class 1: Infant sleep state Awake (Sia) Appears asleep (Sis); Indeterminate (SIX) Modifiers: Class 1: Relative distances Touching/physical contact, within arms reach, beyond mothers arm reach Or Class 8 crib separate room

20. Sleep Lab Component: At the non-population level, “outcomes” are not fully explained by “practice” ?

21. Getting at how, if, or to what degree sleep environment “outcomes” are embedded within a larger psycho-social and emotional (living) context? Ethnographic narratives by mothers (perception and practice) who does she get information from?) knowledge of safety issues, motivations, reasons for, and explanations of sleeping arrangements, feeding, and nurturing behavior matched to behavior… observation of daytime/nighttime quality of care: proximity to infant, attachment, safety, testing consistency between day and nighttime caregiving (first study of its kind);

22. “Getting at “outcomes” ..as embedded within a larger analytical framework Testing for, and charting…infant development verbal readiness, cognition, pro-social behavior in relationship to community-social and maternal support; Testing for maternal change…and differences between between teen and high resource moms; Does a teens need for more sleep compromise quality of nighttime infant care? Scoring at 4 and 8 months..continuity in nighttime care over time?

23. In-Home Behavioral Observation(at 2 and 4 months) Contingent Responsiveness Adults and adolescents display high level of responsivity, but group means are consistently higher for adults Physical Intrusiveness (guarding, monitoring, mentoring) Adults slightly more intrusive than adolescents General Verbal ness Adults talking to infants almost continuously; adolescents talking to infants approximately half of the time These in home measures are based on use of the Landry Naturalistic Observation Rating Scale Contingent responsiveness measures mothers’ prompt and sensitive response to the child’s signals and overall involvement with the child --for this sample, both adolescents and adults are highly responsive, but the adults score consistently higher, and this difference is statistically significant at this point. Physical intrusiveness measures physical expressions of impatience, abruptness in respositiiong, and removing or threatening to remove things from the child. General verbalness refers to mother’s “conversation” with her childThese in home measures are based on use of the Landry Naturalistic Observation Rating Scale Contingent responsiveness measures mothers’ prompt and sensitive response to the child’s signals and overall involvement with the child --for this sample, both adolescents and adults are highly responsive, but the adults score consistently higher, and this difference is statistically significant at this point. Physical intrusiveness measures physical expressions of impatience, abruptness in respositiiong, and removing or threatening to remove things from the child. General verbalness refers to mother’s “conversation” with her child

24. Father Involvement at 4 Months Adolescent Adult Daily contact 52% 90% Less than once 10% 0% per month Everyone else is in between, but these extremes again highlight some key group differences. This data only represents those mothers who were willing to answer questions about the baby’s father or those who know who the father is, so the difference is potentially somewhat higher.Everyone else is in between, but these extremes again highlight some key group differences. This data only represents those mothers who were willing to answer questions about the baby’s father or those who know who the father is, so the difference is potentially somewhat higher.

25. In your mind, how are babies supposed to sleep? Where did you learn this? (3 Moms) Mother 1: “I think that babies should lay on their sides, because to me if you lay them on their backs, they could choke, or on their stomach. Myself” Mother 2: “Babies should sleep in a position most comfortable and safest for them to be on..like their backs or stomachs, Babies roll from front to back, from side to side” Mother 3 Some say on back, some say on tummy, I usually lay her on her side”

26. Where Will Your Baby Sleep (Pre-natal Questionairre)

27. Sleep and Feeding Behaviors (South Bend Home Sample) Adolescent Adult Sleep Location Crib Separate Room 0% 13% Crib Same Room 40% 0% Crib Next to Bed 0% 33% In Bed with Mom 60% 30% Breastfeeding Initiation 20% 66% Breastfeeding is notably absent among the teen sample, and although data on continuation rates has not yet been released, anecdotal data indicates that the duration of breastfeeding is significantly shorter than for the adult sample.Breastfeeding is notably absent among the teen sample, and although data on continuation rates has not yet been released, anecdotal data indicates that the duration of breastfeeding is significantly shorter than for the adult sample.

28. SLEEP LAB SOUTH BEND SAMPLE: “WHAT HAVE YOU LEARNED ABOUT HOW TO MAXIMIZE YOUR INFANT’S SAFETY DURING SLEEP?” PLACE INFANT ON BACK (25%) DON’T SLEEP WITH BABY (9%) SLEEP WITH BABY (SAME BED) 3% NOTHING IN CRIB (12%) Keep away from pillow (9%) PROTECT HEAD/FACE FROM OBSTRUCTION (10%) introduce risk due to mis-understanding (8%) at least one risk disregarded or contradicted (9%)

29. Noldus Observational Technology: Behavioral Repertoire-Procedure One Week Sleep Diary Pre and Post Sleep Questionnaire; Lounge Observations: responsiveness, verbal ness, praising, guarding, mentoring; Observations of Sleep Period Time Classes of Behavior Scored: Feeding Method/Timing /Durations Sleep/Wake Status Maternal Nighttime Responses-Latencies (asleep/Awake) protective,affectionate, non-affectionate (punitive) Infant sleep position and behavior facing; Risks encountered: falls, head coverings, blanket wrappings,

30. Video Infra Red Photography all mothers signed IRB approved statements approving the showing of these video tapes to scientific audiences

31. Feeding Risks: Bottle Propping Sequence 1: inappropriate use of blankets and pillows to minmize mother’s sleep disruption; Scored as:

32. Infra-red nighttime video Behavioral observations(unsafe sleep practices)  Sequence 1 maternal behavioral emotional non-reactivity and/or indifference to infant elicitations (vocal and tactile); illustrates notion that parents and infants bring their relationship into the bed--into the “practice” making it safe or unsafe;

33. Infra-red Nighttime Behavioral Observations(unsafe infant sleep practices) Sequence 1 infant placed prone to nap on couch (single teen mom;) Sequence 2 blanket wrapped around infant neck (older mom) infant placed on pillow (older mom); Sequence 3 infant sleeps face-down (prone) alone in separate room;

34. High-Education Adult Mother (36 y.) Mixed feeding strategy; crib separate room Mild depression scores Prenatal alcohol use High contingent responsiveness Low general verbalness In your mind, how are babies supposed to sleep? Where did you learn this? “She should be able to sleep through the night at 6 months. I learned this from my friends.” Mixed feeding strategy involves bottle of formula before bed—done to promote sleep and extend period between onset of sleep period and first night waking. This mother consistently concerned with extreme organization of the environment immediately surrounding the infant. Here, in the lounge before bed, the infant is draped with toys and books and is set in her car seat in front of the television to watch a Baby Einstein video. Similarly, extreme measures taken to construct a comfortable sleep environment for the infant, which ultimately proves to be inappropriate and hazardous in a number of ways—You will see that this mother has the infant sleep on top of one blanket and with a small baby pillow, swaddled in another blanket with a third blanket on top, and a smaller blanket wrapped around the infant’s neck. Subsequently, you’ll also see what happens to all this soft bedding only minutes afterward, where the baby gets the blankets up and over her entire head and face. Mixed feeding strategy involves bottle of formula before bed—done to promote sleep and extend period between onset of sleep period and first night waking. This mother consistently concerned with extreme organization of the environment immediately surrounding the infant. Here, in the lounge before bed, the infant is draped with toys and books and is set in her car seat in front of the television to watch a Baby Einstein video. Similarly, extreme measures taken to construct a comfortable sleep environment for the infant, which ultimately proves to be inappropriate and hazardous in a number of ways—You will see that this mother has the infant sleep on top of one blanket and with a small baby pillow, swaddled in another blanket with a third blanket on top, and a smaller blanket wrapped around the infant’s neck. Subsequently, you’ll also see what happens to all this soft bedding only minutes afterward, where the baby gets the blankets up and over her entire head and face.

35. What Moms Know, What they do! “Never put a baby on its stomach and keep blankets out of crib” But maybe this does not apply to an adult bed?

36. One sleep environment to another? “What have you learned about how to maximize your infant’s safety during sleep?” “Keep pillows and toys out of the crib”

37. Perceptions of What Risk Warnings Mean “There should not be a lot of bulky pillows or toys in the bed which he could get pressed up against”

38. High-Education Adult Mother (24 y.) Breastfeeding; crib separate room High depression scores Prenatal cigarette use High contingent responsiveness Low general verbalness Have your views about infant sleep changed since your baby was born? “Yes—there were many sleepless nights the first couple of months. He slept on his back at first but he slept on his tummy when he first got sick to breathe better. Now I can’t get him ‘back’ to sleep.” This mother displays very affectionate behavior throughout the night, and is in very close physical proximity to her infant for the vast majority of the observation period. She is also an exclusively breastfeeding mother at 4 months, and the infant typically begins the night on a separate surface, but finds his way into the mother’s bed at the first nocturnal feeding session—which reminds us that sleep and feeding are intricately related behaviors, and this also reinforces the findings of other studies that show that breastfeeding mothers virtually always end up sleeping with their infants for some part of the night whether they initially intended to cosleep or not. Also note that this mother reported prenatal smoking (and the interviewer was even shown a picture of her 8 months pregnant with cigarette in hand), and uses the prone position when the infant is sleeping outside of her bed. She is a nurse and acknowledges that the prone position is not recommended by doctors, but feels that this position has facilitated the baby’s breathing at times when he has been sick, so she actively chooses to disregard this piece of medical advice.This mother displays very affectionate behavior throughout the night, and is in very close physical proximity to her infant for the vast majority of the observation period. She is also an exclusively breastfeeding mother at 4 months, and the infant typically begins the night on a separate surface, but finds his way into the mother’s bed at the first nocturnal feeding session—which reminds us that sleep and feeding are intricately related behaviors, and this also reinforces the findings of other studies that show that breastfeeding mothers virtually always end up sleeping with their infants for some part of the night whether they initially intended to cosleep or not. Also note that this mother reported prenatal smoking (and the interviewer was even shown a picture of her 8 months pregnant with cigarette in hand), and uses the prone position when the infant is sleeping outside of her bed. She is a nurse and acknowledges that the prone position is not recommended by doctors, but feels that this position has facilitated the baby’s breathing at times when he has been sick, so she actively chooses to disregard this piece of medical advice.

39. Adolescent Mother (19 y.) Bottle feeding; crib same room No depression Prenatal cigarette use High contingent responsiveness High general verbalness In your mind, how are babies supposed to sleep? Where did you learn this? “On their backs or sides—from my parents and doctors.” This mother is extremely interactive with her infant, and displays virtually non-stop affectionate and protective behaviors with the baby, as well as a steady stream of verbal interactions. She uses a crib next to her bed for the infant, and we see her structuring this environment appropriately—with no pillows or blankets at all, and just sleeper pajamas to keep the infant warm. During night wakings, we also see that the infant does not cry, and even during sleep, the mom promptly arouses in response to increased movement from the baby. This mother is extremely interactive with her infant, and displays virtually non-stop affectionate and protective behaviors with the baby, as well as a steady stream of verbal interactions. She uses a crib next to her bed for the infant, and we see her structuring this environment appropriately—with no pillows or blankets at all, and just sleeper pajamas to keep the infant warm. During night wakings, we also see that the infant does not cry, and even during sleep, the mom promptly arouses in response to increased movement from the baby.

40. Preliminary Observations The dyad in the context of a larger social sphere is the unit of study. Any given child care practice is complex and diverse. There are some potentially meaningful differences between adult and adolescent mothers Discrepancies in self-reports vs. direct observation No one sleep environment appears inherently safe or unsafe. Rather, infant sleep safety varies as a function of age, experience, individual parenting perceptions, interpretations, confidence in institutions vs. family members, and interpretations of the needs of a particular infant. Supplementing existing research with naturalistic observation is important because it gives us an idea of what people actually do with their infants at night. Self-reports vs. direct observation often create distinctly different pictures of parenting style, so it is important for research on parenting behavior to incorporate direct observation. This study will provide an opportunity to compare reported vs. observed nighttime sleep and feeding data both at individual time points and assessing change over time. These case studies reinforce the idea that no one sleep environment is inherently safe or unsafe, but rather that infant sleep safety varies as a function of individual parenting practices, and this may have some implications for what types of information is given to parents about how to approach sleep safety. These tape clips show both safe and unsafe sleeping environments in the same space using identical furniture—the only variable is what mothers DO with those pieces of furniture. I feel that I’m understating the case when I say that it is inadequate for the CPSC to state simply that every infant should sleep in a crib with a tight-fitting mattress, without addressing the individual risk factors that can be introduced into BOTH a crib sleeping or cosleeping situation. Supplementing existing research with naturalistic observation is important because it gives us an idea of what people actually do with their infants at night. Self-reports vs. direct observation often create distinctly different pictures of parenting style, so it is important for research on parenting behavior to incorporate direct observation. This study will provide an opportunity to compare reported vs. observed nighttime sleep and feeding data both at individual time points and assessing change over time. These case studies reinforce the idea that no one sleep environment is inherently safe or unsafe, but rather that infant sleep safety varies as a function of individual parenting practices, and this may have some implications for what types of information is given to parents about how to approach sleep safety. These tape clips show both safe and unsafe sleeping environments in the same space using identical furniture—the only variable is what mothers DO with those pieces of furniture. I feel that I’m understating the case when I say that it is inadequate for the CPSC to state simply that every infant should sleep in a crib with a tight-fitting mattress, without addressing the individual risk factors that can be introduced into BOTH a crib sleeping or cosleeping situation.

41. Multi-facetted Discourse on Bedsharing: Who (else) And What (else) Must Be Considered? Physiological (biological) studies of infant sleep while bedsharing amongst breast feeding and non-breast feeding dyads; Ethnographic-home data on parental decision making, sleep behavior, and sleeping arrangements; Lactation consultants and studies of the biological links between infant sleep proximity and breast feeding promotion; Case control studies with standardized definitions and new variables; Those most effected by public health recommendations including local citizens, WHO, UNICEF, DHHS

43. Acknowledgements Special Thanks to: Ms.Lane Volpe Ms. Kristin Klingaman Dr. John Borkowski Dr. Jennifer Burke Lefever