Effects of Prematurity on the Social and Emotional Development of School Age Children: Implications and Conclusion

Implications of these studies

By Michelle Bell

Despite the limitations of this research, the findings consistently underscore the need to understand premature children and their mothers in their own right and not just in reference to healthy full-term infants and their parents. Firstly, mother's emotional state following the birth of a premature infant needs to be understood within the context of some basic psychological parameters linked to the internal aspects of maternal bonding. From a psychoanalytical point of view, primary maternal preoccupations refers to the mother's mental life during the immediate post-birth period, which contribute to the formation of a selective and enduring bond, critical to maternal responsiveness. Indeed the current findings that prolonged separation together with anxiety leads to depression in mothers of premature children supports the assumptions of primary maternal preoccupations in the early post-natal period.

Rather than relying on normative measures of post-natal depression derived from clinical populations, clinicians dealing with premature mothers may need to determine a mother's capability of entering the relational bond with her infant following prolonged separation. Assessment of maternal anxiety may be a useful starting point along with measures tapping depressive mood. If a premature mother reports an abnormal amount of caring anxiety or depression (including sub-clinical depressive mood) these symptoms would need to be taken seriously and clinicians would be well advised to monitor and intervene where possible. A goal of intervention during the Newborn Intensive Care Unit (NICU) stay may be to enhance the mother's thoughts of her infant by promoting frequent skin to skin contact with her infant and providing consistent opportunities for parents to be involved in their infant's care. Mothers who rapidly engage themselves with their premature infant in the hospital nursery have been shown to be more sensitive to their infants needs (Minde, 2000) and are less likely to experience feelings of grief and loss following discharge (Goldberg & DiVitto, 2002).

As well as considering the role of maternal anxiety and depression in the NICU environment, the results of the current study also suggest that these emotional responses may not be immediately reversible following the discharge of the infant. In the process of meeting the needs of the premature infant, who is often described as fragile and easily disorganized (Field, 1979), the mother may feel 'out of tune' with her infant, and may not have at her disposal an affective or behavioural response that complements her infant's development. In addition, premature mothers often experience feelings of guilt, anger and despair having given birth to a premature infant and often have difficulty obtaining and comprehending information about her infant (Minde, 1984). Taken together these points suggest that clinicians need to be particularly sensitive to the difficulties premature mothers may have in expressing their fears and anxieties concerning both their own well being and their infants functioning.

A further important theme of the current investigation is the findings that premature infants, who were hospitalized for prolonged periods, were adversely affected by this experience regardless of their mother's emotional state. Indeed, it appears that the hospital environment, which demands that an infant cope predominantly in the absence of the nursing mother by its very nature, fails to foster healthy ego development.

Fortunately, a great body of literature over the past 15 years has recognized the importance of early psychological development in premature infants and hospital practices have shifted towards encouraging parents to participate in the care of their infants (Goldberg & DiVitto, 2002; Minde, 200). Arguably, the most dramatic change in caring for these special infants evolved from research demonstrating the benefits of 'kangaroo care' whereby a mother carries her infant in an upright position on her chest in a sling. The advantages of kangaroo care are best illustrated in developing countries such as Colombia where due to economic constraints, and lack of incubators, premature infants in satisfactory conditions, no matter how small, go directly to their mother as early as two hours following birth (Anderson, Marks & Wahlberg, 1986).

Research that has documented the outcome of these premature infants report dramatic reductions in mortality and parental abandonment when compared to those infants who were separated for prolonged periods from their primary care giver (Anderson, Marks & Wahlberg, 1986). Reflecting on mother-infant proximity, Anderson et al. noted that skin to skin contact, nurturance and warmth seem to provide the ideal environment for premature infants. These findings led others (Eckerman & Oehler 1992; Field, 1990) to conclude that kangaroo care may also enhance parental confidence that leads to maternal responsiveness and subsequent bonding. The challenge to Western medical technology is to find the correct balance between providing the benefits of modern medical interventions while simultaneously supporting the developing parent-infant relationship pertinent to maternal investment and subsequent infant ego development.

While hospitals now encourage parents to participate in kangaroo care, there is still a need to further promote these practices in Western NICU institutions. As mentioned previously, medical procedures alone still account for the majority of social and physical contact a premature infant endures whereas mothers account for a mere 14 percent (Eyler, Woods, Behnke & Conlon, 1992 cited in Goldberg & Divitto, 2002). These data requires us to think of new ways of empowering parents to participate in the care of their infants and participate in kangaroo care. Perhaps interventions that include an educational component concerning the benefits of such practices like kangaroo care may be a useful starting point. A particularly interesting question for future research is whether the right balance of kangaroo care can moderate the effects of prolonged separation on ego development and or primary maternal preoccupations.

Of further relevance, the current path model that begins with prolonged hospital care and ends in behavioural disturbances may well apply to children who have undergone prolonged hospital admissions in early infancy for reasons other than prematurity. As already noted, children who have undergone medical procedures in early infancy that required prolonged hospitalization are twice as likely to develop an emotional or behavioural deficit in early childhood (Minde, 2000). As Minde suggests our current knowledge about attachment, indicates that the behavioural and emotional disturbances experienced by both premature and non-premature hospitalized infants in later childhood may well be due to the disruption of the infant's developing attachment to his or her primary care giver. Like premature infants, hospitalized infants often have to cope with numerous medical staff each day (Minde, 2000) and although hospitals now engage in attentive nursing care, nursing care is not an approximation of parental care (Minde, 2000; Goldberg & Di Vitto, 2002).

Finally, the current model revealed a direct pathway, suggesting that the weaker ego maturity of children, hospitalized for prolonged periods, leads to poor social functioning, which in turn explained 25% of the variation in attention difficulties. Overall, these findings could be taken to suggest that premature children are more likely to suffer with Attention Deficit Hyperactivity Disorder (ADHD). This interpretation is consistent with much outcome literature which document similar findings (e.g. Hack, Breslau, Aram, Weissmen, Klein & Borawski-Clark, 1992; Breslau, Brown, DelDotto, Kumar, Ezhuthachan, Andreski & Hufnagle, 1996; Szatmari, Saigal, Rosenbaum & Campbell, 1993).

In fact Szatmari et al. (1993), have stated that the behaviour problems of premature children may represent a relatively pure form of ADHD, a claim supported by many other investigators (e.g., Hack, Breslau, Aram, Weissman, Klein & Borawski-Clark, 1992; McCormick, Gortmaker & Sobol, 1990).

However, this thesis cautions against labelling the attention problems of premature children with a diagnosis such as ADHD. Instead, the behaviours constituting the attention factor on the Child Behaviour Checklist (e.g. acts young, cant concentrate, confused, stares) could be conceptualised as a failure to achieve certain age appropriate goals; this conceptualisation raises the question of why this may have occurred. Rather than taking a diagnostic perspective, this thesis suggests that clinicians dealing with premature children may need to take a developmental approach that involves viewing the observed behaviours as possible deficits stemming from earlier developmental delays. Assessment of the premature child's ability to involve him or herself in interpersonal relationship would be a useful starting point in clarifying the nature of behaviours otherwise assumed to reflect ADHD. In addition, the current results imply that a premature child may feel overly dependent on others but at the same time feel that others are less likely to respond or be assessable to their needs. Since it is these characteristics that have found in premature children, this thesis argues that closer attention to the development of social maturity (i.e., ego development) seems warranted.


Overall, the results of this study support the assumptions of the transactional model (Sameroff & Chandler, 1975), in that they emphasize the need to understand the complexity of mutual influences that operate between the premature infant and his or her primary care giver that together may serve to either moderate or perpetuate the effects of earlier developmental delays; namely, bonding. In particular, the current study underscores the need to examine the attachment relationship from the mother-to-child rather than simply from child-to-mother. Indeed the integration of psychoanalytical thought has been advocated by Bowlby (1958) himself as the ultimate road to understanding the attachment process and has been shown in this study as a useful way of understanding premature mother-infant bonding.

According to this framework, the length of a premature infant's hospitalization has serious implications for the mother's developing tie to her infant. That is, prolonged separation of premature infants from their mothers has been shown to result in mothers experiencing greater anxiety and this appears to develop into depressive mood. This emotional state was shown to persist following the discharge of premature infants and was predicative of later adverse childhood functioning.
Still another set of events that affect a premature infant's development may also be the infants limited capacity to enter the symbiotic phase of development pertinent to ego development during their hospital stay and possibly beyond. Evidence for this assumption was found in that premature school aged children in the current study reported weaker ego maturation, regardless of their mother's emotionality, when compared to those children who remained in proximity to the nursing mother. Moreover, weaker ego maturity appears to lead to poorer social behaviours characterized by feelings of dependency, loneliness and difficulties engaging in interpersonal relationships. Not surprisingly, the poor social functioning of premature children led to attention problems resembling relative immaturity, and the inability to focus.

Both Object Relations theory and Winnicott's (1956) psychoanalytical account of the mothers mental life following birth, state that this period is characterized by a unique mental and developmental repertoire that is directed at maintaining mother-infant physical and psychological proximity crucial to bonding and subsequent development. Although the current study sought to understand the process of premature children's development from a psychoanalytical angle, this approach is not intended to pathologize this group. Rather, this study highlights compelling reasons that may explain why premature infants and their mothers bring different elements to early social interaction patterns that in turn may lead to adverse child development.

That is, the results of this study should be taken as a framework that outlines the psychological processes influencing a premature child's early years of development that is not comparable to those already outlined for full-term infants. Given this understanding, clinicians dealing with premature mother-infant dyads can implement preventative strategies that support the development of internal bonding processes operative for both premature mothers and their premature infants. While modern medical technology continues to improve the survival rate of premature infants, our knowledge concerning the importance of bonding can only serve to improve the healthy development and well being of these very special infants.

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