Comunicación Publicitaria y publicidad social

This chapter provides a summary of the major findings related to the overall aim from the four studies undertaken, followed by a discussion integrating the findings with the literature. Furthermore, the strength and limitations of the research will be discussed. Lastly, implications of the findings and suggestions for future research will be presented.

This thesis set out to determine the predictive role of neurodevelopmental

vulnerability and sensitive parenting on multiple regulatory problems. Moreover, it investigated the association between multiple regulatory problems and infant-mother attachment.

Summary of Results

To investigate the independent or conjoint effect of neurodevelopmental vulnerability on regulatory problems across the first 18 months of age, it was

important to first determine whether it was possible to use a naturalistic experimental design. In particular, using a mixed sample of infants born with neurodevelopmental vulnerability (i.e. born preterm or full-term) to determine the effect of

neurodevelopmental vulnerability without a confounding effect on maternal

sensitivity. For this purpose, a meta-analysis was conducted to determine whether the stress associated with preterm birth may alter maternal sensitivity of caretakers of preterm children. The meta-analytic investigation (study 1) indicated that

neurodevelopmental vulnerability, i.e. preterm birth did not alter maternal sensitivity of mothers compared to mothers of full-term born infants. Thus, it was justified to

use a sample comprising both preterm and full-term infants to investigate the effects of neurodevelopmental vulnerability and maternal sensitivity on the development of regulatory problems and infant attachment. Study 2 investigated whether VP/VLBW infants experienced higher levels of single and multiple regulatory problems

compared to FT infants across the first 18 months. It was found that

neurodevelopmental vulnerability was associated with an increased rate of multiple regulatory problems at term and 18 months. Study 3 explored the longitudinal association between initial neurodevelopmental vulnerability, and interplay of

maternal sensitivity and multiple regulatory problems over the first 18 months of life. Applying a cross-lagged model of multiple regulatory problems and maternal

sensitivity over 3 time points, it was found that neurodevelopmental vulnerability had a continuing effect on multiple regulatory problems at term and 18 months. Maternal sensitivity at term was associated with multiple regulatory problems at 3 months but maternal sensitivity at term or 3 months did not have an impact on regulatory problems at 18 months nor did the empirical results indicate any cross influences of multiple regulatory problems on maternal sensitivity. Finally it was tested in study 4 if multiple regulatory problems are predictors of later insecure or disorganised attachment. Study 4 found that once controlled for maternal sensitivity and other confounders, multiple regulatory problems as early as 3 months were associated with both security of attachment and even more strongly with disorganised attachment to the mother.

Integrated Discussion

Neurodevelopmental vulnerability operationalized by preterm birth was found to have no adverse impact on maternal sensitivity compared to maternal sensitivity in

literature have suggested that prematurity adversely impacts parenting (Forcada- Guex et al., 2006; Korja et al., 2012; Schermann-Eizirik et al., 1997), the current meta-analysis revealed no evidence for an influence of preterm birth on maternal sensitivity. Regardless of the stressful experiences during NICU stay after preterm birth (Goldberg & DiVitto, 2002), mothers of preterm children engage with their infants in a similar sensitive manner as those of full term children. This finding is in correspondence with the results of another meta-analysis study, which revealed maternal sensitivity as similar in samples with and without autism spectrum disorders (van Ijzendoorn et al., 2007). The findings indicate considerable resilience of

mothers who are able to show similar sensitive caretaking despite early infant-related stressful experiences. Mothers of preterm children show considerable adjustment in their behaviour despite increased stress experience (Savage-McGlynn et al., 2015). Although neurodevelopmental vulnerability did not relate to maternal sensitivity, it contributed to the development and maintenance of multiple regulatory problems. This is consistent with a previous study that reported that very preterm birth was a strong predictor of multiple regulatory problems at 5 months (Schmid et al., 2011). Moreover, other studies highlighted that more neurological immaturity (Papoušek & von Hofacker, 1995) and elevated levels of respiratory sinus arrhythmia (Dale, O‘Hara, Keen, & Porges, 2011b) in infants were associated with multiple regulatory problems compared to those not affected by regulatory problems. Furthermore, both neurodevelopmental vulnerability and regulatory problems are associated with the same behavioural outcome in the long-term, namely ADHD (Hemmi et al., 2011; Johnson & Marlow, 2011; Lindstrom, Lindblad, & Hjern, 2011). Thus, children’s under-regulation behaviour is likely to be preceded by neurodevelopmental

of this finding to other samples at risk for neurodevelopmental problems (Papoušek & von Hofacker, 1995). Since feeding problems have been consistently more frequent in preterm samples, it may be that the combinations including feeding regulatory problems might be more strongly associated to neurodevelopmental vulnerability compared to combined crying and sleeping problems. However, our sample size was too small to investigate the various permutations of multiple regulatory problems.

Maternal sensitivity had some but only short-term impact on multiple regulatory problems during infancy, which is consistent with previous literature regarding the development of childhood behavioural problems (Ciciolla, Gerstein, & Crnic, 2014; Hartz & Williford, 2015). The absence of bidirectional associations between general maternal sensitivity and multiple regulatory problems across infancy contradicts the transactional model of development which puts a strong emphasis on the impact of bidirectional influences between mother and child on the development of

problematic behaviours (Sameroff, 2009). A plausible explanation is that the strength of bidirectional associations between maternal and child behaviour could vary with respect to the developmental period during which the analysis is conducted. The bidirectional association between mother and child behaviour has usually been documented in studies with older children (Eisenberg, Taylor, Widaman, & Spinrad, 2015; Serbin, Kingdon, Ruttle, & Stack, 2015). In particular, the influence of child on maternal behaviour may become more apparent with advancing age (Burke, Pardini, & Loeber, 2008) since children become more independent as they get older. Our findings suggest that multiple regulatory problems are moderately persistent despite sensitive parenting from 3 months onwards.

While interpreting our findings regarding maternal sensitivity, it should be acknowledged that the current thesis evaluated general maternal sensitivity as observed in play situations. Hence, our findings might not be applicable to sensitive parenting in other settings, which are closely linked to regulatory problems such as while feeding a regular meal, during soothing, or night-time sleep practices

(Lindberg et al., 1996; Philbrook & Teti, 2016). However, there is evidence that maternal sensitivity is consistent across different settings such as bathing and free play in infants without regulatory problems (Joosen, Mesman, Bakermans-

Kranenburg, & van Ijzendoorn, 2012), and during feeding and free play in children with feeding problems (Atzaba-Poria et al., 2010). Nevertheless, it was important for the purpose of the current thesis to measure maternal sensitivity in a play situation. If maternal sensitivity was observed during regulatory problem related situations such as during crying, then maternal behaviour might be a reaction to high stress demand in regulating the behaviour under consideration (regulatory problems) and the measure of maternal sensitivity, partly measured as reaction of the infant to maternal behaviour, would result in confounding the measurement of infant behaviour. Thus, while in clinical settings mothers may present with inappropriate ways to deal with infant crying or sleep problems, this may be a reaction rather than a cause of the multiple regulatory problem according to the findings here. Thus, if observed outside dealing with the behaviour of interest (regulatory problem) such as in a play

situation, this is more likely to be a representation of maternal sensitivity in general or maternal potential for sensitivity.

Multiple regulatory problems are relatively stable over time, consistent with the reports from other longitudinal studies (Schmid et al., 2010; Wake et al., 2006; Winsper & Wolke, 2014). A new finding is that multiple regulatory problems were

as stable as maternal sensitivity over time. During the first few months, infant behaviour undergoes rapid changes (Lamb, Bornstein, & Teti, 2002) and usually there is very limited stability in areas such as cognitive development (Bremner & Fogel, 2004). On the other hand, maternal behaviours tend to be more stable even during infancy (Behrens, Hart, & Parker, 2012). Hence, this finding is quite remarkable and an indication that regulatory abilities at the extreme (multiple

regulatory problems) are moderately enduring characteristics of the infant. Likewise, numerous studies in the field of “difficult” temperament research revealed that temperamental characteristics are relatively stable from infancy to childhood (Hayes, McCoy, Fukumizu, Wellman, & DiPietro, 2011; Komsi et al., 2006; Pedlow, Sanson, Prior, & Oberklaid, 1993).

A further novel finding is that multiple regulatory problems were found to be associated with both insecure attachment over and above maternal sensitivity, and highly associated with disorganised attachment. This finding highlights that although having multiple regulatory problems did not impact on maternal sensitivity it

impaired the infants’ attachment behaviour towards their mother. Accordingly, infant characteristics that indicate behaviour organisation are shown to be crucial for the developing relationship of infant to the mother even when mothers are sensitive. Due to the lack of previous empirical studies that examined the relationship between multiple regulatory problems and attachment, one can only speculate whether attachment style may be a mediator or moderator of the relationships between early regulatory problems and the development of externalizing and internalizing

problems. It has been established by meta-analysis studies that both regulatory problems (Hemmi et al., 2011) and disorganised attachment (Fearon et al., 2010) are risk factors for the development of externalizing problems in childhood and beyond.