The regression analysis with the BABS as the independent variable, and number of health conditions and education as covariates, and DAIS score as the dependent variable was not statistically significant overall. Only education reached statistical significance (P = .08) with a standardized beta coefficient of −0.24 (ie, parents with higher educations reported lower DAIS total scores).
Because this work has been framed in an exploratory context, an additional regression analysis was conducted with the DAIS dimension score that was most different among the countries: carrying. The same model was run, and in this case, the model was significant within our set alpha level (P = .09). Eleven percent of the variation in carrying score was statistically supported by the BABS score (P = .04, standardized beta coefficient = 0.27) and education (P = .08, standardized beta coefficient = −0.24). Parents with less perception of their infants' vulnerability, and those with less education, provided more opportunities through their carrying activities for the development of antigravity postural control.
Finally, we were interested in the highly statistically significant variation in availability of services among the 3 countries. Results of t tests on both the BABS and the DAIS scores between those receiving services and those not receiving services for the combined sample are contained in Table 5. Interestingly, parents who received therapy services had greater perceptions of their infants' vulnerability than parents not receiving services. There was no statistically significant difference in DAIS scores; however, there is a small trend for those receiving services to have lower DAIS scores. To understand the sources of variation in perceptions of vulnerability, we compared GA, BW, and number of health conditions between those receiving services and not through independent t tests. Only number of health conditions was significantly different (t = 3.30, df = 56, P = .002), with those receiving services having fewer health conditions (mean = 1.0, SD = 1.1) than those not receiving services (mean = 2.1, SD = 1.3). The proportion of infants with IVH and having been discharged home on oxygen were compared between those receiving services and not using chi-square. No significant differences were detected. Periventricular leukomalacia was not included in this post hoc analysis, because all 3 infants were from the Netherlands, and all received services. Finally, we investigated the correlations between the BABS scores and GA, BW, and number of health conditions using Pearson's correlation coefficient and between the BABS scores and IVH and discharged home on oxygen using the point biserial correlation. No significant correlations were obtained.
The results associated with the primary purpose of this study were not anticipated. First, given the predominance of the prematurity stereotyping literature from North America, we anticipated that Canadian parents might perceive their infants to be more vulnerable than parents in either Norway or the Netherlands. In fact, in this study, parents in the Netherlands perceived their infants to be more vulnerable. Second, although the total DAIS scores were not significantly different among the 3 countries, parents in the Netherlands reported lower carrying and higher sleeping scores than parents in Canada, with parents in Norway being in the middle of these 2 countries. These results are not attributable to possible differences in the actual vulnerability of the children in terms of their GAs at birth, BWs, or number of health conditions or the ages of the children at the time they participated in the study (ie, selection bias does not explain these results). Although parents in the Netherlands had greater perceptions of vulnerability than parents in Canada and Norway, there was no association between perceptions of vulnerability and childrearing practices supporting early motor development (controlling for number of health conditions and parental education) when looking at the total DAIS score. However, when looking at the DAIS dimension score of carrying, 11% of the variance in how parents carried their infants was attributed to both perceptions of vulnerability, in the expected direction, and education, in a direction that was not expected. In interpreting these results, recall that the DAIS total and section scores are composed of both amount of time and extent of challenge. These results therefore provide some support for the hypothesis that parents' beliefs about their children's vulnerability contribute in some way to their childrearing practices to support early motor development. A surprising finding was the result that parents who were receiving therapy services perceived their infants as more vulnerable than those not receiving therapy services.
Despite the lack of definitive information on the variable reasons that children and families received services, as well as lack of information on the frequency, intensity, duration, focus, and setting of intervention, the results of this study lead us to wonder if receiving therapy services is as uniformly beneficial (at best) or benign (at worst) as we commonly assume. Is it possible that the mere fact of receiving services actually contributes to parents' perceptions of their children's vulnerability? Is it possible that therapy services contribute to this phenomenon by focusing on deficits and possible adverse outcomes rather than taking a strength-based perspective? Does a focus on deficits actually contribute to higher perceptions of vulnerability? Conversely, might it be possible that taking a strength-based perspective avoids adverse outcomes associated with prematurity stereotyping? What is the content and focus of therapy that leads to optimal outcomes of these high-risk infants?
In a Cochrane review of the randomized (n = 6) and quasi-randomized (n = 10) intervention trials conducted within the first 12 months of life with infants born preterm published between 1966 and February of 2006, little evidence was found for the effectiveness of early interventions on motor outcomes in the short (birth to 2 years), medium (3 to <5 years), and long (5–17 years) terms.28 The authors concluded that “[t]he heterogeneity between early developmental intervention programs in regard to content, focus and intensity limit the conclusions that can be drawn from this review.”28(pp18-19) They recommended that future work should target interventions to address the needs of the infant and family more specifically. A more recent systematic review including literature up to June 2008 focused on interventions involving parents (eg, teaching parenting skills and/or involving parents in the hospital care of the infant) found some evidence of effectiveness; however, effects were found to be greater (and sustained longer over time) on cognitive rather than motor outcomes.29 These authors concluded “[i]t remains of great importance to identify effective interventions to improve the long-term outcomes of this vulnerable population and their families.”29(p349)
Along these lines of thinking and recommendations, a recently published study focused intervention between hospital discharge and 6 months corrected age on specific suggestions to parents to support their infants' functional competence, guided by infants' behavior, and to adjust the environment according to the infants' needs to enhance postural control and successful infant explorations.30 This approach resulted in higher motor competencies at 24 months than those receiving regular care. Importantly, the intervention was tailored to each parent-infant dyad by first providing parents with information about each infant's unique development and then using anticipatory guidance to suggest the functional abilities that would likely emerge next.30 Our recommendations for future research, described next, are entirely consistent with this approach.
We believe that future work should consider multiple aspects to support intervention, and should be longitudinal instead of cross sectional, as reported here. It would be useful to recruit a sample with greater representation of all educational levels so that the role of education could be more fully explored, and more strategies put in place to support families. A measure of parents' perceptions of their infants' vulnerability based on motor competencies should be developed. A more refined instrument may assist in illuminating potential relationships between parents' perceptions of their infants and their childrearing practices to support the early functioning of these infants. Reliability of this new scale should be established. Work also needs to be conducted to assist with interpretation of the DAIS scores. What values are typically obtained from parents of infants born at term, and how do these scores compare with scores from parents higher risk infants born preterm? One variable that was not considered in the current work was birth order. Future work should consider parents' experiential knowledge of raising other children, either born full-term or preterm, and potential effects on perceptions of vulnerability. In addition, the potential determinants of parents' perceptions of vulnerability and their childrearing practices to support motor development logically need to be linked to infant motor development. Given our fundamental belief that the manner in which parents physically interact with their infants has the potential to either enhance or hinder early physical activity, investigating the potential effects of an educational package using the DAIS is warranted. Using parent-friendly, pictorial materials such as the AIMS25 and the DAIS24 together, along with systematic observations of the unique characteristics of the infant, parent's perceptions of infant vulnerability relating to motor competencies, and the environment in which the infant is developing,31 has the potential to assist parents in many ways. This package of materials might help parents understand their infants' current motor repertoire, anticipate the motor behaviors that will likely emerge next, explore the “fit” between their childrearing practices to support motor development as measured by the DAIS and their infants' motor competencies and unique characteristics, engage their infants in more challenging DAIS items on a routine basis throughout their daily activities, and modify the environment in which the child lives to support development of antigravity postural control and movement exploration. The feasibility and acceptability of this comprehensive approach is currently being explored on a longitudinal sample of infants from 4 to 11 months of age. A focus group will be held at the end of the pilot work to ascertain how to make this package most engaging to parents of infants at risk for developmental disabilities. This approach is consistent with recommendations by others who have highlighted the importance of a strengths- and process-based approach to support the parent-infant relationship and the infant's emerging functions.30
We recognize significant limitations in this study. First, we were not successful in recruiting our target sample size within the funding period of this study. This work can only be seen as preliminary and exploratory. Second, the aspects of vulnerability captured in the BABS may be too generic and not related specifically to motor competence, as indicated earlier. Third, some parents had difficulty in scoring the DAIS, which led to 3 cases being excluded from the analysis. These 3 parents had relatively lower levels of education (1 in Norway had not completed high school and 2 in Canada had just completed high school). More detailed instruction needs to be considered with some parents if the DAIS is used in future work. Fourth, we did not have access to uniform data to ascertain actual vulnerability with respect to developmental status at the time the data were collected. As a result, our query about the potential effect of participation in therapy as contributing to perceptions of vulnerability is only speculative, but in our opinion, a possibility that is worth thinking about.
Despite the inherent limitations of this study, we did not find any support for the notion that prematurity stereotyping is exclusively a North American phenomenon. We have some evidence that parents' perception of their children's vulnerability contributes to opportunities they provide these infants to develop antigravity postural control through the ways in which they carry their infants. The finding that parents whose infants were receiving therapy services perceived their infants as more vulnerable suggests to us that we might need to be vigilant about potential harmful effects of therapy services. Our results, in the context of recent literature, suggest that future research should investigate strength-based and relationship-focused interventions to support infant motor development, childhood motor performance and fitness, and long-term health in this high-risk group of those born preterm without definitive neurological conditions such as CP.
The authors thank Jeanne van der Burgt and Katerina Steiner (the Netherlands) and Unn Inger Moinichen and Marthe Eggesvik (Norway) for their assistance with data collection and Inge-Lot van Haastert for ongoing conversations.
1. Slattery MM, Morrison JJ. Preterm delivery. Lancet. 2002;360:1489–1497.
2. de Klein MJ, den Ouden AL, Kollee LA, et al. Lower mortality but higher neonatal morbidity over a decade in very preterm infants. Paediatr Perinat Epidemiol. 2007;21:15–25.
3. de Kleine MJK, den Ouden AL, Kollee LAA, et al. Outcome of neonatal care for very preterm infants at five years of age; a comparison between 1983 and 1993. Paediatr Perinat Epidemiol. 2007;21:26–33.
5. Goyen TA, Lui K. Longitudinal motor development of “apparently normal” high-risk infants at 18 months, 3 and 5 years. Early Hum Dev. 2002;70:103–115.
6. Williams J, Lee KJ, Anderson PJ. Prevalence of motor-skill impairment in preterm children who do not develop cerebral palsy: a systematic review. Dev Med Child Neurol. 2010;52:232–237.
7. Falk B, Eliakim A, Dotan R, Liebermann DG, Regev R, Bar-Or O. Birth weight and physical activity in 5-to-8-year old healthy children born prematurely. Med Sci Sport Ex. 1997;29:1124–1130.
8. Burns YR, Danks M, O'Callaghan MJ, et al. Motor coordination difficulties and physical fitness of extremely-low-birthweight children. Dev Med Child Neurol. 2009;51:136–142.
9. Rogers M, Fay TB, Whitfield MF, Tomlinson J, Grunau RE. Aerobic capacity, strength, flexibility, and activity level in unimpaired extremely low birth weight (≤800 g) survivors at 17 years of age compared with term-born control subjects. Pediatr. 2005;116:e58–e65.
10. Keller H, Ayub BV, Saigal S, Bar-Or O. Neuromotor ability in 5- to 7-year old children with very low or extremely low birthweight. Dev Med Child Neurol. 1998;40:661–666.
11. Bartlett DJ, Fanning JK. Use of the Alberta Infant Motor Scale to characterize the motor development of infants born preterm at 8 months corrected age. Phys Occup Ther Pediatr. 2003;23(4):31–45.
12. Bartlett D, Piper MC. Neuromotor development of preterm infants through the first year of life. Phys Occup Ther Pediatr. 1993;12(4):37–55.
13. Davis BE, Moon RY, Sachs HC, Ottolini MC. Effects of sleep positioning on infant motor development. Pediatr. 1998;102:1135–1140.
14. Lee AM. Child-rearing practices and motor performance of black and white children. Res Quart Ex Sport. 1980;51:494–500.
15. Hopkins B, Westra T. Maternal handling and motor development: an intracultural study. Genet Soc Gen Psychol Monogr. 1988;114:377–408.
16. Abbott AL, Bartlett DJ, Fanning JEK, Kramer J. Infant motor development and aspects of the home environment. Pediatr Phys Ther. 2000;12:62–67.
17. Lin CC, Fu VR. A comparison of child-rearing practices among Chinese, immigrant Chinese, and Caucasian-American parents. Child Dev. 1990;61:429–433.
18. Nugent JK. Cross-cultural studies of child development: implications for clinicians. Zero to Three: Natl Center Clin Infant Progr. 1994;15:1–8.
19. Adolph KE, Karasik LB, Tamis-LeMonda ST. Motor skills. In:Bornstein MH, ed. Handbook of Cultural Developmental Science. New York: Taylor & Francis; 2010:61–88.
20. Green M, Solnit AJ. Reactions to the threatened loss of a child: a vulnerable child syndrome. Pediatr. 1964;34:58–66.
21. Stern M, Hildebrandt KK. Prematurity stereotyping by mothers of premature infants. J Pediatr Psychol. 1988;13:255–263.
22. Arbuckle TE, Wilkins R, Sherman GJ. Birth weight percentiles by gestational age in Canada. Obstet Gynecol. 1993;81:39–48.
23. Perrin EC, West PD, Culley BS. Is my child normal yet? Correlates of vulnerability. Pediatr. 1989;83:355–363.
24. Bartlett DJ, Fanning JK, Miller L, Conti-Becker A, Doralp S. Item generation and psychometric testing of the Daily Activities of Infants Scale: a measure of participation supporting antigravity postural control and movement exploration. Dev Med Child Neurol. 2008;50:613–617.
25. Piper MC, Darrah J. Motor Assessment of the Developing Infant. Philadelphia, PA: Saunders; 1994.
26. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum; 1988.
27. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 2nd ed. Oxford: Oxford University Press; 1995.
28. Spittle AJ, Orton J, Doyle LW, Boyd R. Early developmental intervention programs post hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev. 2007;18(2):CD005495.
29. Vanderveen JA, Bassler D, Robertson CMT, Kirpalani H. Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis. J Perinatol. 2009;29:343–351.
30. Koldewijn K, van Wassenaer A, Wolf MJ, et al. A neurobehavioral intervention and assessment program in very low birth weight infants: outcome at 24 months. J Pediatr. 2010;156:359–365.
31. Doralp S. Affordances in early motor development: the role of contextual factors. PhD Dissertation. London, Ontario, Canada: The University of Western Ontario; 2009.
APPENDIXArticles on Prematurity Stereotyping and Vulnerable Child Syndrome
Allen EC, Manuel JC, Legault C, Naughton MJ, Pivor C, O'Shea TM. Perception of child vulnerability among mothers of former preterminfants. Pediatr. 2004;113:267–273.
Green M. Vulnerable child syndrome and its variants. Pediatr Rev. 1986;8:75–80.
Perrin EC, West PD, Culley BS. Is my child normal yet? Correlates ofvulnerability. Pediatr. 1989;83:355–363.
Shonkoff JP. Reactions to the threatened loss of a child: a vulnerablechild syndrome, by Morris Green, MD, and Albert A. Solnit, MD, Pediatr. 1964; 34:58–66. Pediatr. 1998;102:239–241.
Stern M, Hildebrandt KA. Prematurity stereotype: effects of labeling onadults' perceptions of infants. Dev Psychol. 1984;20:360–362.
Stern M, Hildebrandt KA. Prematurity stereotyping: effects on mother-infant interaction. Child Dev. 1986;57:308–315.
Stern M, Hildebrandt KK. Prematurity stereotyping by mothers ofpremature infants. J Pediatr Psychol. 1988;13:255–263.
Stern M, Hildebrandt Karraker K. Modifying the prematurity stereotype:the effects of information on negative perceptions of infants. J SocClinical Psychol. 1989;8:1–13.
Stern M, Hildebrandt Karraker K. Modifying the prematurity stereotypein mothers of premature and ill full-term infants. J Clin Child Psychol. 1992;21:76–82.
Stern M, Hildebrandt Karraker K, Meldrum Sopko A, Norman S. The prematurity stereotype revisited: impact on mothers' interactionswith premature and full-term infants. Infant Ment Health J. 2000;21:495–509.
Stern M, Karraker K, McIntosh B, Moritzen S, Olexa M. Prematu-rity stereotyping and mothers' interactions with their premature andfull-term infants during the first year. J Pediatr Psychol. 2006;31:597–607.
Thomasgard M, Metz WP. The vulnerable child syndrome revisited. Dev Behav Pediatr. 1995;16:47–53.
Canada; childrearing; health status; infants; mothers/psychology; Norway; premature; premature infants; social perception; the Netherlands