An Examination of Adolescent Maternal–Infant Attachment

AN EXAMINATION OF ADOLESCENT MATERNAL–INFANT ATTACHMENT

RELATIONSHIP OUTCOMES FOLLOWING A

FIRSTPLAY® THERAPY INFANT STORYTELLING-MASSAGE INTERVENTION:

A PILOT STUDY

Karen M. Baldwin

A Capstone Project Submitted to the Faculty of

Phyllis and Harvey Sandler School of Social Work

In Partial Fulfillment of the Requirements for the Degree of

Doctor of Social Work

Florida Atlantic University

Boca Raton, FL

May 2020

iii

ACKNOWLEDGEMENTS

The author would like to thank her committee members who have contributed to this capstone through their encouragement, helpfulness, and support. Special thanks to my committee chair Dr. Thompson and committee member Dr. Gail Horton for their patience, support, encouraging words, and constant guidance throughout this process. I would like to thank my family for being there for me and always supporting me in all ways possible. I would like to dedicate this capstone to my father Lyle Merriman and the memory of my mother, Patricia Merriman for providing a loving and secure childhood.

My life experiences have grounded me in pursuing the importance of early-attachment relationships for all children and in return, provided the motivation for this project. I also would like to dedicate this capstone to Dr. Janet Courtney, who, with her many years of being an educator to me, mentor, and friend, has brought forth an inspiration to continue to work toward new ways of intervening and assisting families with attachment relationships. This capstone is for both of them.

iv ABSTRACT

Author: Karen M. Baldwin

Title: An Examination of Adolescent Maternal–Infant Attachment Relationship Outcomes Following A FirstPlay® Therapy Infant Storytelling-Massage Intervention: A Pilot Study

Institution: Florida Atlantic University

Capstone Advisor: Dr. Heather Thompson

Degree: Doctor of Social Work

Year: 2020

Adolescent mothers experience many factors that affect their ability to securely attach to their infants and are therefore considered a high-risk population. In addition, infants of adolescent mothers are at an increased risk of developing insecure attachment.

FirstPlay® Therapy Infant Storytelling-Massage is an attachment-based, parent–infant adjunctive play therapy model founded on the theoretical underpinning of attachment theory.

The current study implemented a one-time intervention with an adolescent mother population in a group home setting. A pretest/posttest design was utilized to measure the impact of FirstPlay® Therapy on the variables of an adolescent mother’s levels of maternal attachment and comfort with physical touch. Participants in this study (N = 5)

were adolescent mothers ages 18–21 years old, who were recruited from four maternity group homes in two counties in South Florida. Five adolescent mothers completed the

FirstPlay® Therapy for pre and posttest data. No significant differences were found in the areas of maternal attachment and predisposition to touch before and 2 weeks after the intervention. There were some significant relationships found among the demographic variables specific to an adolescent mother’s history of employment status and her child welfare history as well as the age of the mother and the age of her infant. In addition, at posttest, a significant relationship was found between the sex of the infant and the total score on the PCAQ. Although no statistically significant findings were presented, recommendations for further research include extending this intervention to a broader population of adolescent mothers across a variety of settings to focus on early infant- attachment relationships.

Although further studies are needed to expand on the current one, this study provides insight into the feasibility of teaching infant massage storytelling as a component of a group maternity-home curriculum. The findings of the study can be used to guide the implementation of future attachment intervention research addressing the maternal-attachment relationship with an adolescent mother population.

AN EXAMINATION OF ADOLESCENT MATERNAL–INFANT ATTACHMENT

RELATIONSHIP OUTCOMES FOLLOWING A FIRSTPLAY® THERAPY INFANT

STORYTELLING-MASSAGE INTERVENTION: A PILOT STUDY

LIST OF TABLES ...... ix

LIST OF APPENDICES ...... xi CHAPTER 1 ...... 1 Context and Purpose of the Study ...... 1

Purpose of the Study ...... 3

Research Aims ...... 5

Research Questions ...... 5

Definitions of Key Terms ...... 6

Rationale for the Study ...... 7

CHAPTER 2 ...... 14 Conceptual Framework and Review of the Literature ...... 14

Theoretical Framework ...... 14

Attachment Theory ...... 14

Literature Review...... 20

Cognitive Readiness...... 21

Maternal Sensitivity ...... 22

Adolescent Mothers and Depression ...... 24

Maternal Attachment Representations ...... 26

Infant Massage and Research on Touch ...... 28

vii

Summary ...... 30

CHAPTER 3 ...... 32 Methods...... 32 Study Design and Hypotheses ...... 32

Sample...... 34

Sample Recruitment Procedures ...... 34

Data Collection ...... 36

Intervention Sites ...... 36

Informed Consent Processes ...... 39

Implementation ...... 40

Intervention ...... 41

Instruments ...... 45

Data Analysis ...... 49

CHAPTER 4 ...... 51 Results ...... 51

Bivariate Correlations ...... 51

Regression ...... 53

Cross Tabulations and Chi Square Analyses ...... 53

Paired sample t-tests ...... 54

CHAPTER 5 ...... 55 Discussion and Implications ...... 55

Hypothesis 1...... 55

Hypothesis 2...... 56

Hypothesis 3...... 59

Limitations ...... 60

Implications for Future Research ...... 62

viii

Implications for Practice ...... 66

Conclusion ...... 67

Appendices ...... 76

References ...... 91

LIST OF TABLES

Table 1. Baseline Participant Characteristics ...... 69 Table 2. Correlational Table ...... 71 Table 3. Cross Tabulation: Age of Mother in Years;Age of InfanSO yot in Weeks ...... 73 Table 4. Cross tabulation: Mother’s Current Status of Employment; Mother’s Child- Welfare History ...... 74 Table 5. Paired Sample Test for Maternal Attachment Inventory and Physical Contact Assessment Questionnaire ...... 75

LIST OF APPENDICES

Appendix A: Demographic Questionnaire …………...... 76

Appendix B: Maternal Attachment Inventory……………...... 77

Appendix C: Physical Contact Assessment Questionnaire ...... 80

Appendix D: Daily Log ...... 83

Appendix E: Medical Consent Form ...... 85

Appendix F: Parental Consent Form ...... 87

Appendix G: Parent Review Checklist ……………………………………………….... 90

CHAPTER 1

Context and Purpose of the Study

In 2009, researchers, found that the United States has the highest number of adolescent pregnancies of any nation that tracks such data, with an estimated one in six women nationwide projected to become adolescent mothers (Beers & Hollo, 2009). As of

2016, pregnancies among adolescent girls in the United States have decreased; however, rates are still substantially higher than other western industrialized nations (Romero et al.,

2016). Mothers who parent as adolescents often encounter many parenting struggles to greater degrees than adult mothers. These include higher rates of depression, less social support and education, greater potential for substance abuse, poverty, fewer employment skills, and more dependence on government support (Long, 2009). Adolescent mothers have been found to be less knowledgeable than older mothers about normal child development; they engage less positively with their babies and are not as aware of their babies’ needs, which can lead to poorer child outcomes (Long, 2009). Adolescent mothers also tend to interact less positively with their infants and have unrealistic expectations of their infants’ development compared with adult mothers (Beers & Hollo,

2009). These factors can increase the risk of adolescent mothers’ infants developing insecure attachment. Ainsworth (1978) stated that insecure attachment relationships can develop when primary caregivers are not sensitive to their infants, for example, those who respond to their infants’ needs incorrectly or who are impatient or ignore their

infants. In addition, an adolescent mother’s own insecure attachment, often due to a history of childhood abuse, can also affect the attachment relationship between her and her infant (Ensink et al., 2016). These mothers are more likely to display inappropriate affect toward their infants, role and boundary confusion, frightening and disorienting behavior, and intrusive and negative behavior compared with non-adolescent mothers

(Madigan et al., 2006).

Multiple factors can affect an adolescent mother’s maternal–infant attachment relationship, impacting her ability to securely attach to her infant (Beers & Hollo, 2009).

Infants of adolescent mothers are therefore at a heightened risk for developing insecure attachment, which can lead to lifelong mental, physical, health, and social disorders

(Grabbe, 2015). Research has shown that insecure attachment can lead to developmental delays, academic difficulties, behavioral disorders, and later high-risk behaviors such as substance abuse or antisocial behavior (Klein, 2005). Additionally, Grabbe (2015) found that children who develop insecure attachment can be at risk for mental health difficulties that may encompass personality and dissociative disorders.

In the early 21st century, several researchers in the field of neuroscience discovered that human brains are shaped by our earliest relationships. Early development of the human brain is stimulated by the physical and emotional interactions between parents and children (Badendoch, 2008). Siqveland (2014) found that the quality of interaction between the infant and primary caregiver during the first year of life is vital for the child’s brain development. He stated that early experiences between caregiver and infant can affect the brain in a positive or negative way, thereby shaping the infant’s ability to function socially and emotionally. Bernier and colleagues (2016) also found

that the parent–child relationship has an overwhelming influence on the development of the child’s brain. In addition, a systematic review of the literature found that children from inadequate environments characterized by neglect, abuse, or extreme relational deprivation (e.g., orphanages) exhibited the profound impact that these adverse conditions can have on normal brain development (Badenoch, 2008; Ensink et al., 2016;

Madigan et al., 2006; Schore & Schore, 2012). These researchers have concluded that

brain growth may be affected by extreme distress. Additionally, healthy brain

development can be positively influenced by early parent–child relationships that are

nurturing. According to Badenoch (2008), human brains are hardwired for attachment,

and therefore, the infant seeks interpersonal nourishment in order to structure the brain

for future healthy relationships and personal well-being.

Adolescent mothers face many factors that can affect their ability to securely

attach to their infants and are therefore considered a high-risk population (Long, 2009).

In addition, infants of adolescent mothers are at an increased risk of developing insecure

attachment, making it imperative to reach out to this high-risk population and provide

appropriate services. It is important to study interventions that promote healthy maternal–

infant attachment relationships, because insecure attachment can result in deficient child

outcomes.

Purpose of the Study

The purpose of this study is to examine the effect of an adjunctive play therapy model called FirstPlay® Therapy Infant Storytelling-Massage Intervention (FirstPlay®

Therapy) on maternal attachment and comfort with physical touch using a pretest posttest

design. FirstPlay® Therapy (Courtney, 2015) is an attachment-based, parent–infant resiliency model grounded in attachment theory.

FirstPlay® Therapy also includes infant massage, a component supported by research specific to the benefits of touch (Field, 1998; Field et al., 2000; Field, 2011;

Oswalt et al., 2009). In addition, making it uniquely different from other infant massage interventions, FirstPlay® Therapy incorporates Ericksonian-based therapeutic storytelling. Mills (2015) adapted Milton Erickson’s work to a play-therapy model she titled StoryPlay®. Ericksonian storytelling implements indirect positive messages that are embedded within a story to “activate inherent healing processes that can reach a child at a deeper level of consciousness” (Courtney & Mills, 2016, p. 19). In addition, recent research in the area of literacy has shown that the more parents and caregivers speak to infants face to face, where an infant can see a parent speaking and the more words a parent speaks, the better a child eventually performs in school (Hillairet de Boisferon et al., 2017).

The FirstPlay® Therapy model is also supported by developmental play therapy

(DPT) developed by Dr. Viola Brody in the 1960s (Brody, 1997). Brody maintained that the use of touch as a therapeutic intervention was the core of DPT. Brody believed that touch helps the child produce the conditions necessary for the development of an “inner self,” which is a basic human necessity for healthy emotional growth (Brody, 1997).

Moreover, she surmised that these experiences in early infancy and childhood of both physical and emotional relationships could impact later development (Brody, 1997).

FirstPlay® Therapy methods are designed to be implemented along with other forms of parent/infant interventions as well as preventative education and modalities.

FirstPlay® Therapy is practiced by trained practitioners from diverse helping professions

who model, guide, facilitate, and supervise parents to provide attuned, caring, and

respectful touch to their infants in order to form healthy maternal–infant attachment

relationships (Courtney, 2015).

Although this model of intervention has not been tested with an adolescent mother

population, its tenets are supported by the conceptual underpinnings of attachment

theory. The purpose of this study is to implement FirstPlay® Therapy in a one-time pilot pretest/posttest study with an adolescent mother–infant dyad. The study is aimed at enhancing the maternal–infant attachment relationship.

Research Aims

Predicated on the above problem statement, this study was guided by the

following research aims:

1. To examine the preliminary effects of FirstPlay® Therapy on the maternal–infant

attachment relationship of adolescent mother–infant dyads.

2. To examine the preliminary effects of FirstPlay® Therapy on adolescent

mothers’ predisposition to touch.

3. To determine if there is a relationship between the maternal–infant attachment

relationship and the adolescent mothers’ predisposition to touch.

4. To report on the frequency and consistency of implementing FirstPlay® Therapy

with a 14-day daily log.

Research Questions

1. Will there be an increase in maternal–infant attachment for adolescent mothers pre

and posttest (2 weeks later) after implementation of FirstPlay® Therapy?

2. Will adolescent mothers have increased positive feelings about physical contact

with their infants 2 weeks after implementation of FirstPlay® Therapy?

3. Will there be a positive correlation between maternal attachment and the

adolescent mothers’ predisposition to touch after participating in FirstPlay®

Therapy?

Definitions of Key Terms

The following definitions of key terms were used in this study:

• Secure attachment: A strong, positive emotional bond between infant and primary

caregiver (Benoit, 2004). Infants with secure attachment are able to use their

caregivers as a “secure base” (Bowlby, 1988, p. 11) from which to explore the

world. An infant is willing to venture away from the caregiver to engage in age-

appropriate exploration and play. When an infant who is securely attached becomes

separated from its caregiver, that infant is able to be comforted and soothed by the

caregiver when reunited (Bowlby, 1988).

• Insecure attachment: A bond that forms between an infant and primary caregiver

that is lacking in consistency, responsiveness, and full trust and may cause the

infant to feel anxious, angry, distressed, or conflicted (Benoit, 2004). Children with

insecure attachment may be less inclined to explore and may not be easily

comforted when reunited with a caregiver (Ainsworth et al., 1978; Egeland &

Farber, 1984). Children with insecure attachment may experience rejection by a

primary caregiver, fostering a tendency to avoid showing negative emotions they

experience during relational distress (Ainsworth et al., 1978).

• Adolescence: A transitional period of growth, development, and maturation that

begins at the end of childhood and ends with the entry into adulthood. Adolescence

begins at approximately the age of 10 and continues to age 21 years (Pratt, 2006).

The onset of puberty signals the beginning of adolescence; the end of adolescence is

marked by the individual reaching full physical and developmental maturity or

young adulthood (Pratt, 2006).

• Adolescent mother: For this study, a young person between the ages of 18–21 years

old who has undergone puberty and who has not reached full maturity but is

pregnant or parenting a child (Cox, 2007).

• Infant: The period of life between birth and the acquisition of language, which is

approximately at one year old (Allen & Waterman, 2017; CDC, 2017).

• Maternal attachment: An interactional process that seems to flow in one direction,

mother toward infant, beginning with acquaintance and moving over time toward

attachment (Goulet et al., 1998).

• Predisposition to Touch: A trait reflecting an individual’s comfort with being

touched and using touch with others (Weiss & Wilson, 2006).

Rationale for the Study

Intervention studies in adolescent mother–infant dyads and the attachment relationship are limited. Only a few outcome studies have examined interventions to increase secure attachment with this population (Crugnola et al., 2016; Mayers et al.,

2008; Nicolson et al., 2013; Oswalt et al., 2009). The purpose of this study was to evaluate infant massage as an intervention to promote the attachment relationship.

Previous intervention research on infant massage has focused mainly on the premature

infant population and showed positive effects on infant development, the mother–infant

interaction, and the mother’s own psychological well-being (Field, 1998). However, most

of these studies were designed with researchers or medical staff providing massage for

the infants, failing to capture the impact and potential benefits of infant massage training

for mothers (Field, 1998; McClure, 2000; Scafidi & Field, 1996). There were a few

studies in which mothers provided the infant massage, and these studies found benefits

for infants, including weight gain, decreased infant stress , improved sleep, and decreased

excitability (Field, 1998; Field et al., 2004; Pados, 2019).

In studies in which mothers have applied infant massage, researchers have also

found benefits to the mother such as decreased depression and anxiety (Fiejo et al., 2006;

Field et al.,1998; O’Higgins et al., 2008; Oswalt et al., 2009) more appropriate caregiving

behaviors, and more positive mother–infant interactions (Feldman, 2011, Field, 2011;

Hertenstein, 2002; O’Higgins et al., 2008). One of these studies focused on utilizing the

technique of infant massage with an adolescent mother–infant dyad population (Oswalt et

al., 2009). This comparison study of 25 adolescent mother–infant dyads participating in a

parent training program for high school students, randomly assigned participants to an

intervention (n = 9) or control group (n = 16). Participants received a brief 30-minute training on infant massage and were then asked to do daily massage with their infants for two months. The researchers hypothesized that adolescent mothers who learned and utilized infant massage would experience a decrease in their levels of depression and stress and an increase in their maternal confidence and positive feelings about physical contact with their infants. In addition, the researchers hypothesized that by utilizing infant massage, the adolescent mothers’ own perceptions of their infants’ temperament would

be more adaptive. Data analysis was based on the 15 participants (control group n = 8, intervention group n = 7) who completed the baseline and two-month follow-up measures. Pretest/posttest measures utilized in this study were the Parental Stress Index

(PSI; Abidin, 1995) and the Beck Depression Inventory II (BDI–II; Beck et al., 1996).

Pretesting revealed that the mothers in the intervention group reported low levels of comfort and experience with physical contact and were less knowledgeable about child development than those in the control group. Posttesting supported the researchers’ hypotheses, with mothers in the intervention group reporting increased levels of comfort in physical contact with their infants as well as a positive influence on their perceptions of their infants’ temperament compared to the control group (Oswalt et al., 2009). It must be noted that some of the limitations to this study that the current study was intended to address were the low retention rate and the inability to monitor compliance with the daily massage log. In addition, this intervention did not incorporate responsive interaction and verbalization from the mother to the infant that the current study will facilitate through the infant storytelling-massage. Research has shown that interactive experiences of infant massage with an attuned and sensitive caregiver are vital precursors to higher forms of social, emotional, and cognitive development (Courtney, 2015).

Another outcome study conducted in Australia by Nicolson and colleagues (2013) utilized a brief perinatal attachment intervention as part of routine maternity care with adolescent mothers and their infants called Adolescent Mothers’ Program: Let’s Meet

Your Baby as Person (AMPLE). In this study, researchers compared a group of 35 adolescent mothers receiving the AMPLE intervention with a group of 38 adolescent mothers receiving regular maternity care. AMPLE involved two interactive phases: Phase

one was implemented in the antenatal period. Participants viewed a video that highlighted

aspects of parenting and the need for parents to connect to their infants. Phase two was

given in the neonatal period with mothers receiving individual sessions to explore their

infants’ social capacity and to encourage connection. These researchers found both

statistical and clinical significance in their results, with the intervention sample

displaying notably increased emotional availability and maternal sensitivity as well as

decreased maternal hostility and intrusiveness with their infants. An aim of the current

study was to build on past research that has emphasized early intervention and been focused on attuned interactions between adolescent mothers and their infants in order to benefit the mother–infant attachment relationship (Nicolson et al., 2013).

A similar study conducted in Italy by Crugnola and colleagues (2016) utilized an attachment-based intervention called “Promoting responsiveness, emotion regulation and attachment in young mothers and their infants” (PRERAYMI; p. 3). An interdisciplinary team composed of psychologists, infant neuropsychiatrists, and psychomotorists facilitated the intervention. These researchers aimed to increase the mother’s sensitivity to her infant while also reducing the more controlling behaviors, such as excessive

handling of the infant’s body, raised tone of voice and hyperstimulation. Researchers

used three distinct strategies in this intervention program: (a) video intervention, (b)

psychological counseling, and (c) developmental guidance. In the video intervention,

Crugnola et al. (2016) utilized a cognitive behavioral approach by highlighting

observations of the mother–infant interactions, pointing out both positive and negative

interactional patterns. The psychological counseling assisted the adolescent mother with

her transition into motherhood as well as aiding her to reflect on her own history of any

past trauma. Developmental guidance was also offered to the mothers. Psychomotorists

monitored the infant’s motor and cognitive development by utilizing the Bayley Scale

(Bayley, 2005) at six and ten months old. The results allowed the researchers to discuss

the developing skills of the infant and any problems with the mothers. The researchers

found that this intervention was effective in increasing maternal sensitivity and

decreasing the mothers’ hostility toward their infants. One of the limitations of this

particular study was the limited variables examined. Although Crugnola et al. (2016)

examined maternal sensitivity, they did not consider the variable of comfort with physical

touch for the mothers in regards to their infants. In the current study, the variables of the

maternal–infant attachment relationship will be examined from the perspective of the

mothers as will the mothers’ perceived feelings on touch through infant massage

(Crugnola et al., 2016).

Mayers et al. (2008) conducted an intervention study on Chances for Children, a

teen- parent-infant program located in two high schools aimed at utilizing individual,

dyadic, and group interventions to strengthen the relationship between an adolescent

mother and her infant. Specifically, these interventions focused on encouraging mothers

to use reflectivity rather than reaction and thoughtful reflections rather than impulsivity

with their infants. Ten-minute videotapes of mother–infant dyads in free play were

analyzed using the Maternal Behavior Rating Scale (MBRS; Mahoney et al., 1985). In

addition, self-report measures were utilized to assess stress and depression in the

adolescent mothers. The researchers’ findings confirmed their hypotheses that adolescent

mothers who received the intervention (n = 52), compared to adolescent mothers in the control group (n = 33), improved their interactions with their infants in the areas of

responsiveness, affective availability, and directiveness. Additionally, this relationship

proved to be mutually beneficial, because the infants also increased their interest in their

mothers, responded more positively to physical contact, and improved their overall

emotional tone. This study also found that although a subset of the sample of mothers

scored above the clinical cutoff for depression prior to the treatment intervention, this did

not compromise the mothers’ ability to improve the mother–infant interaction. These

researchers discussed the importance of these findings, as adolescent mothers often demonstrate a higher incidence of depression. The current study expanded on these

findings of an infant’s positive responses to physical touch as well as the adolescent

mothers’ increased affect availability by incorporating infant massage and storytelling

that the adolescent mother herself can provide and implement on a daily basis.

Although adolescent mothers can be a challenging population to engage and

retain in preventive programs, attachment intervention can support the adolescent

maternal–infant dyadic relationship (Crugnola et al., 2016; Mayers et al., 2008; Nicolson

et al., 2013; Oswalt et al., 2009). All four studies identified above found clinically and

statistically significant results in improving the mother–infant attachment relationship.

Effective services have been home based, school based, or utilized in a hospital setting.

These studies have shown that even brief, preventive interventions can be effective with

this vulnerable population. However, additional research and outcome studies are needed

in the area of infant attachment with this high-risk population. A goal of this study was to

address shortcomings in previous studies by examining additional variables such as the

maternal–infant attachment relationship as well as the adolescent mothers’ own

perception of touch in order to add to best practice of care for this population (Beers et al., 2009).

CHAPTER 2

Conceptual Framework and Review of the Literature

Theoretical Framework

FirstPlay® Therapy is a play therapy model predicated on the theoretical

underpinning of attachment theory. To gain a solid understanding of FirstPlay® Therapy

and its application to the adolescent maternal–infant attachment relationship, this underlying theory will be presented, as well as its relevance to this intervention.

Attachment Theory

Attachment theory focuses on the nature and quality of interactions between a parent or a primary attachment figure and the child and how that contributes to psychological, emotional, and social health or pathology (Courtney, 2015). The theory originated from the work of John Bowlby, a British child psychiatrist and psychoanalyst

(Bowlby, 1969). In the 1950s, Bowlby theorized that during the first year of life, infants form a type of psychological connection with their caregivers known as attachment

(Bowlby, 1969). Bowlby discovered that something occurred when children received warm, consistent, and responsive attention from their primary caregivers (Carlson, 2005).

These children formed a secure attachment that provided the foundation for exploration and normal development, as well as appropriate social development and the ability to interact with others throughout life. Bowlby (1969) stated that human infants needed a consistent and nurturing relationship with an attuned caregiver to develop into healthy

individuals. In addition, Bowlby saw the relationship between the primary caretaker and the infant as not only fulfilling biological drives but also as a primary motivational system. The main function of the system is to promote proximity to the attachment figure and thereby receive a feeling of safety and security for the infant (Bowlby, 1982).

Bowlby (1969) further stated that the importance of the caregiver–infant attachment relationship toward forming secure attachment is based on how quickly, sensitively, and consistently the primary caretaker responds to alleviate the infant’s distress and how attentive and interactive the primary caretaker is in providing pleasure to the infant.

Bowlby (1969) saw the goal of attachment behavior and early survival as two- fold: children need protection and children need to move out and explore. Their instinctive needs are safety, comfort, and protection. When these needs are withheld, the child is at risk of longstanding anxiety and emotional insecurity. According to Keller

(2013), attachment theory is the dominant explanation of how and why attachment develops and how it has evolved as the backbone to survival. Attachment, therefore, is universal and noted across all cultures (Keller, 2013).

Bowlby (1988) proposed that humans construct internal working models of their environment and their own actions within it, which can further enable them to predict the outcome of their behaviors (Bretherton, 1992). The internal working model is a representation of self and others and is formed from the infant’s experiences in early relationships and brought forward into future relationships. Bowlby stated that when a child has repeated experiences of comfort in times of distress, they create a memory schema or an internal working model that lets the child know they have a dependable caregiver in the environment (Bowlby, 1988). This internal working model helps the

infant to formulate a positive representation of an available caregiver which, in turn,

leads to feelings of safety and comfort and the ability to use the primary caregiver as a

secure base. Alternately, an internal working model can also have a negative

representation, such as when a caregiver is unavailable or inconsistent and the infant’s

needs are rejected. This cycle can lead to a self who feels unworthy of love or care,

affecting the caregiver–infant attachment relationship, and can lead to the infant

experiencing difficulty in forming future healthy relationships (Bowlby, 1988).

Bowlby expanded his theory with the collaborative work of Mary Ainsworth. In

1969, Ainsworth became interested in the quality of interactions between a parent or

primary attachment figure and the child and how that could contribute to the

psychological, emotional, and social health of the child (Ainsworth et al., 1971). To

assess differences in the attachment relationship, Ainsworth and colleagues (1978)

developed the laboratory procedure known as the Strange Situation. Ainsworth developed

this procedure on the premise that healthy, attached children might experience distress if

separated from their mother when they are in an unfamiliar environment. This series of

experiments led Ainsworth to identify three types of attachment patterns: secure, insecure-avoidant, and insecure-ambivalent/resistant. She found that with secure attachment, children are able to separate from the mother and explore their environment

(secure base) as well as refer back to the caregiver as needed for reassurance (safe haven). This primary attachment figure provides the child with close, consistent, and nurturing behavior, and in return, the child utilizes behaviors that will bring them closer to the caregiver, such as crying, smiling, clinging, and laughing, for comfort and safety.

Once this attachment occurs, the child uses the primary attachment figure as a secure

base from which to explore, and the primary caretaker is also seen as a safe place to return to when needing comfort or reassurance (Ainsworth et al., 1978). According to

Bowlby (1988) an individual who has experienced a secure attachment is likely to possess a representational model of attachment figure(s) as being available, responsive, and helpful.

The second type of attachment identified by Ainsworth and colleagues (1978) is insecure-avoidant. This type of attachment is categorized by observations of infants whose caregivers consistently respond to distress in insensitive or rejecting ways (Benoit,

2004). These types of behaviors by the primary caregiver may entail ignoring the infant or becoming annoyed by the infant. In response, these infants develop an organized way of attachment in that they deal with their distress by avoiding their caretaker when upset as well as minimizing their negative emotions in front of the caregiver, therefore ignoring their caregiver in times of need (Benoit, 2004). Ainsworth et al. (1978) found these children to be independent of the caretaker both physically and emotionally. As well, the caretaker may be seen as rejecting or disliking the child’s need for dependence, and in return the child may ignore the caretaker when distressed, and may be unresponsive to being held, but protest when put down (Ainsworth, 1978). Stevenson-Hinde and

Verschueren (2002) found that caregivers are often unavailable during times of emotional distress, often leading to infants being at increased risk for developing adjustment problems.

The third type of attachment is insecure ambivalent/resistant (Ainsworth et al.,

1978). In this category, Ainsworth discovered that the child is observed as habitually angry and often has a caretaker who is unable to soothe or comfort the child when they

become distressed (Benoit, 2004). In addition, the child will often exhibit clingy and dependent behavior, but will reject the attachment figure when they become engaged in interaction (Ainsworth et al., 1978). Ainsworth discovered that the child fails to develop any feelings of security from the attachment figure and may be reluctant to explore his or her environment. Ainsworth stated that this behavior resulted from the inconsistent level of response of their needs from the primary caregiver (Ainsworth et al., 1978). Primary caretakers are seen as emotionally unavailable (Benoit, 2004). In addition, Cassidy and

Berlin (1994) found that caregivers with low levels of maternal availability were linked to ambivalent attachment patterns with their infants.

Main and Solomon (1990) added a fourth attachment classification, disorganized- disoriented attachment. Utilizing the Strange Situation setting, they discovered children who were engaged with parents who were unpredictable, frightening or frightened, insensitive, or displayed disruptive parent-child relationships to include conditions such as abuse, neglect, or abandonment (Benoit, 2004). With disorganized/disoriented attachment, the child sees their primary caretaker as a potential source of comfort but also a source of fright, thereby affecting the child’s ability to self-regulate their emotions in regards to the attachment relationship (Benoit, 2004). In return, these children displayed an extreme amount of fear and anxiety over failed attempts to seek protection from a parent. They also displayed disorientation and confusion in their behaviors. These children could eventually develop controlling behaviors in an effort to feel safe (Main &

Solomon, 1990).

Ainsworth and colleagues (1978) discovered that insecure attachments such as ambivalent, avoidant, and disorganized attachments may form when nurturing and

responsive care is lacking or withheld. These insecure attachments can be a result of

many factors, such as a mother’s own maternal representation of her own childhood,

specifically maternal childhood maltreatment (Cramer & Kelly, 2010; Fonagy et al.,

1991; Slade, 2005). Emotional availability of the mother to her infant can also affect the

infant’s ability to self-regulate and lead to insecure attachment styles (Cole et al., 2004).

Maternal sensitivity (Moran et al., 2008) as well as parental mental health and maternal

depression can adversely affect the mother–infant attachment relationship and lead to

insecure attachment (Poehlmann & Fiese, 2001; Barnes & Theule, 2019).

Research has found that a lack of secure attachment can lead to many long-term

emotional effects such as low self-esteem, lack of self-control, aggression and violence,

lack of empathy, neediness, clinging behavior, and oppositional behaviors with parents or

caregivers (Carlson, 2005). This lack of secure attachment has also been correlated to

high risk behaviors in later development such as teen pregnancy, substance abuse, or anti-

social behavior (Carlson, 2005). Catania (2011), for instance, found that children who do

not experience healthy attachment experiences with significant caregivers in their lives

may have difficulty forming healthy relationships. These patterns of insecure attachment

may also lead to neurodevelopmental issues that could further increase the possibility of

future mental health problems. In addition, children who receive disruptive care are more

likely to develop learning, behavioral, and emotional difficulties (Catania, 2011).

As noted, children who do not experience healthy attachment experiences with

significant, other nurturing people in their early lives may find it difficult to form healthy relationships throughout the lifespan. This deficit is most often correlated to high risk behaviors in later development, such as substance abuse, or anti-social behavior (Carlson,

2005). The FirstPlay® Therapy intervention could act as a buffer to these potentially negative outcomes by assisting adolescent mothers to experience meaningful attachment experiences (Courtney, 2015). Practitioners support adolescent mothers to be change agents and to pay attention to their infants’ nonverbal language and cues of engagement.

Through the constructs of attachment theory, FirstPlay® Therapy can help enhance the adolescent maternal–infant attachment relationship. FirstPlay® Therapy can offer a structured way for adolescent mothers to learn new methods of pleasant and tender physical contact that also teach respect for the infant. Attachment theory provides a theoretical structure as well as guidelines for understanding the quality and consistency of effective parent–child bonds that is promoted by FirstPlay® Therapy.

Literature Review

Attachment to a primary caregiver is an innate human need. A maternal–infant attachment relationship develops from a mother’s ability to be reflective, responsive, and sensitive to her infant’s needs. In return, the infant builds trust, confidence, and resilience in later life (Flaherty & Sadler, 2010). Research indicates that securely attached infants have more favorable long-term outcomes in their cognitive, social, and behavioral development (Bernier et al., 2016; Bretherton et al., 2008).

Adolescent mothers face many challenges establishing a maternal–infant attachment relationship, often compromising their behavior with their infants, leading to less-than optimal developmental and socio-emotional outcomes for their infants (Flaherty

& Sadler, 2010). Research in the area of these challenges and consequences to maternal– infant attachment are well documented (Chico et al., 2014; Crugnola et al., 2014; Long,

2009); however, research and outcome studies exploring the maternal–infant attachment

relationship among adolescent mother–infant dyads are limited (Flaherty & Sadler,

2010). Even so, research has shown that when specialized supports are in place to guide and facilitate the maternal–infant attachment relationship with this high-risk population, infants of adolescent mothers have a higher probability of acquiring secure attachment compared to control groups of adolescent mothers not receiving interventions (Crugnola et al., 2016; Mayers et al., 2008; Nicolson et al., 2013; Oswalt et al., 2009).

In this review the current literature is examined on factors that influence the maternal–infant attachment relationship such as (a) cognitive readiness, (b) maternal sensitivity (c) adolescent mothers and depression, and (d) attachment representation.

Lastly, the literature concerning the effects of infant massage and touch will be discussed.

Cognitive Readiness

Ainsworth and her colleagues (1978) found that positive parenting during infancy provides a foundation for the child to feel secure and to develop trust in their caregivers.

However, an adolescent’s cognitive readiness to parent can affect normal adolescent development, which in turn can disturb the necessary maternal behaviors for promoting maternal–infant attachment (Flaherty & Sadler, 2010). Cognitive readiness refers to parenting characteristics that include knowledge of child development, parenting attitudes, and parenting style (Malone, 2006). For adolescent mothers compared to adult mothers, a lack of cognitive readiness has been linked to both maternal and child outcomes (Flaherty & Sadler, 2010; Malone, 2006). Numerous studies have found that adolescent mothers have less knowledge of child development than adult mothers

(Sommer et al., 2000; Whitman et al., 2001) and are also likely to have unrealistic expectations of child development, such as reaching developmental milestones of

crawling, walking, and talking when compared to adult mothers (Tamis-LeMonda et al.,

2002). This lack of knowledge of developmental milestones may also affect maternal expectations of the child’s behavior (Malone, 2006).

This lack of cognitive readiness to parent for adolescent mothers puts the infant at an increased risk for developing disorganized and insecure attachment (Whitman et al.,

2001). A longitudinal study, including 78 adolescent mothers and their infants, examined the quality of maternal interactions and the adolescent mothers’ cognitive readiness to parent (Lounds et al., 2005). Researchers found that cognitive readiness and maternal interactions had a direct effect on the outcome measure of secure attachment, with a majority of their sample displaying insecurely attached infants. However, they also found that verbal encouragement by the mother when the child was age five months predicted the ability of the child to move from insecure to secure attachment. In addition, adolescent mothers have been shown to be less verbally expressive and provide less cognitive and language stimulation to their infants (Barratt et al., 1995; Culp et al., 1991).

Recent research has shown that the more parents and caregivers speak face-to-face with their infants and the more words they speak, the better the children eventually perform in school (Hillairet de Boisferon et al., 2017). Encouraging adolescent mothers to increase direct speaking to their infants could have a positive impact on the adolescent maternal– infant relationship

Maternal Sensitivity

Maternal sensitivity is marked by the mother’s awareness and attention to a child’s cues, while maintaining consistent response patterns and being emotionally available to the child’s needs (Bohr et al., 2010). Ainsworth et al. (1978) originally

described sensitive interactions as linked to the ability of parents to perceive events from the child’s point of view, and properly respond to them. There are limited studies examining maternal sensitivity and the quality of the mother–infant interactions between adolescent mothers and their infants. A study by Crugnola et al. (2014) examined maternal sensitivity through adolescent mothers’ styles of interaction, emotional regulation, and the infants’ responses to the mother. These researchers found that adolescent mothers compared to adult mothers expressed more negative emotion and were more intrusive with their infants by interfering with the activity of the infant through excessive handling of the infant’s body, raised tone of voice, and hyperstimulation (Crugnola et al., 2014). The infants of these mothers reacted by displaying greater negative engagement with the mother. In addition, adolescent mothers spent less time positively engaged with their infants through play objects, which led to more insecure attachment than for infants of adult mothers. The researchers also examined adolescent mothers’ attachment history through the Adult Attachment

Interview (George et al., 1985). Results indicated that adolescent mothers scored higher for their own insecure attachment, which the researchers believed influenced their ability to engage positively with their infants. Furthermore, this study showed that as early as three months old, infants had already begun to have increased negative engagement with their mothers, further increasing the development of insecure attachment. These researchers emphasized the need for early intervention to help guide adolescent mothers by focusing on attuned interactions with their infants as well as regulating their own emotions to increase positive maternal–infant attachment (Crugnola et al., 2014).

Additional studies (see Barratt & Roach; 1995, Berlin et al., 2002; Culp et al.,

1991, Luster & Mittelstaedt, 1993) have found similar results when comparing adult mothers to adolescent mothers in regards to their emotional responsiveness and maternal style of interaction. The studies have shown that adolescent mothers are less affectionate, more detached, and act intrusively when interacting with their infants, in addition to displaying more hostile, negative behaviors, and less positive affect compared to adult mothers. Adolescent mothers also display more controlling behaviors toward their infants, such as more directive behavior characterized by open or implicit hostility, which can contribute to difficulties in the maternal–infant attachment relationship and possibly lead to insecure attachment in the infant (Whitman et al., 2001). All of these factors can negatively affect the maternal–infant attachment relationship.

Adolescent Mothers and Depression

Maternal depression can adversely affect the maternal–infant attachment relationship (Flaherty & Sadler, 2010). Recent research on adolescent mothers has revealed rates of depressive symptoms in the first three months postpartum to be between

53% and 56%, compared with 13% for adult mothers (Logsdon et al., 2005). Depressive symptoms in adolescent mothers have been associated with multiple negative outcomes for both the adolescent mother and her infant (Meadows-Oliver & Sadler, 2010).

Research has shown that the effects of depression on early attachment can, in turn, lead to future physical and behavioral problems for the children (Reid & Meadows-Oliver,

2006).

For adolescent mothers, research has shown that those with depression can have poorer quality of positive interactions with their infants (Reid & Meadows-Oliver, 2006)

as well as impaired maternal–infant interaction (Beck, 1995), diminished gratification in

the maternal role (Killien, 1998), and lower feelings of self-efficacy (Froman & Owen,

1990). In addition, infants of adolescent mothers have poor early maternal–infant

bonding and interactions as well as poor school readiness and self-regulation (Brennan et al., 2000).

Research also has shown that an adolescent mother’s depression can affect the mother’s perception of parenting, which in turn can hinder maternal–infant attachment

(Black et al., 2002; Cox et al., 2008; Luster, 1998; Schmidt et al., 2006;). In one study, researchers examined adolescent mothers with postpartum depressive symptoms and found that these mothers tended to display more frustration and negative emotion when their infants were crying or fussy as well as decreased confidence in their ability to take care of an infant (Secco et al., 2007). In addition, adolescent mothers with depression reported feeling less gratification in the maternal role (Cox et al., 2008), and their increased rates of parenting stress and decreased social support have been correlated with increased symptoms of depression (Spencer et al., 2002). However, social support in the form of community and home has been shown to be a moderator for depression (Cox et al., 2008). In this study, social support was utilized with FirstPlay® Therapy by offering adolescent mothers direct contact with the massage therapist. In addition, the adolescent mothers in this study were also supported by their group-home directors and coordinators and offered additional support if needed within the larger community setting in the form of house parents, therapists, pastoral counseling, and parent education.

Research has shown more negative maternal–infant interactions in depressed adolescent mothers. A study by Panzarine et al. (1995), for example, examined 50

adolescent mothers and their infants. These researchers found that 22 of the adolescent

mothers who reported depressive symptomology were also associated with maternal

depression and negative maternal–infant interactions. Another study conducted by

Leadbeater et al. (1996) found that an adolescent mother’s depression also affected the

reciprocal interactional relationship of the maternal–infant dyad. In a sample of 63

adolescent mothers and their infants, the mother’s depression had a direct effect on the

reciprocal interactions between mother and child at 20 months. Moreover, when

assessing the child’s behavior utilizing the Child Behavior Checklist, preschool-aged children of depressed adolescent mothers displayed increased behavior problems in preschool compared to adolescent mother–toddler conflict responses. A study by Field et al. (2000), conducted on a sample of 260 adolescent mother–infant dyads, found a correlation between depression and less positive feeding interactions as well as infants exhibiting shorter growth length at three months old and smaller head circumference at three months and six months old, as well as more general pediatric complications. These studies are important because of the correlation between adolescent mothers’ depression and maternal–child conflict and increased rates of child abuse (Field et al., 2000;

Leadbeater et al., 1996; Panzarine et al., 1995; Zuravin & DiBlasio, 1996). Each of these factors can potentially affect the maternal–infant attachment relationship negatively.

Maternal Attachment Representations

A mother’s ability to recall her own childhood experiences with her primary caregiver can affect the maternal–infant attachment relationship (Fonagy et al., 1991;

Slade, 2005). Bretherton and Munholland (2008) defined attachment representations as

the way individuals process attachment-related information reflecting the accumulated

attachment experiences throughout development. In addition, attachment representations

are seen as the way a parent develops mental representations of the caregiving

relationship and is thought to be related to a parent’s capacity for sensitive caregiving

interactions (Bretherton & Munholland, 2008). Both Ainsworth et al. (1978) and Bowlby

(1979) indicated that the core concepts of parenting are learned from early relational

experiences in one’s family of origin. In later studies, mothers who received sensitive and

responsive care as children were more likely to be sensitive parents than those who

received insensitive care (Bretherton & Munholland, 2008; van IJzendoorn, 1995).

Adolescent mothers with a history of negative maternal representations have an

increased risk for continuing cycles of maltreatment with their infants (Bartlett &

Easterbrooks, 2012). A maternal history of childhood abuse has been associated with

abusive parenting (Kaufman & Zigler, 1987; Landsford et al., 2007). Mothers who have

been exposed to child maltreatment are at an increased risk of transferring inadequate

social, emotional, and physical well-being to their own children (Brand et al., 2010; Noll

et al., 2009). In 1975, Fraiberg and colleagues coined the term “ghosts in the nursery” to

describe parents’ own reenactments with their children of punitive or neglectful

experiences from their own childhoods. An adolescent mother’s poor maternal

representation from her past can weaken the development of the attachment relationship

with her infant (Fonagy et al., 1991).

A longitudinal comparison study of 112 adolescent mother–infant dyads found that adolescent mothers with a history of childhood sexual and physical abuse, compared to adolescent mothers with no abuse history, were more likely to have insecurely attached infants, which then led to a higher number of externalizing behaviors for those children in

preschool as well as grade three (Pasalich et al., 2016). Other researchers have examined the importance of strengthening the maternal–infant attachment relationship as well as promoting nurturing caregiving in mothers who have a history of maltreatment in order to reduce the risk of their offspring becoming victims of childhood abuse themselves (Jaffee et al., 2013; Thornberry & Henry, 2013).

A study by Crockenberg (1987) found that adolescent mothers who had experienced their own childhood rejection by their caregivers showed more angry and punitive behavior toward their own children. dePaul & Domenech (2000) found similar results in a comparison study of adolescent mothers to adult mothers, showing that adolescent mothers with their own abuse history had an increased risk of maltreating their children (dePaul & Domenech, 2000). An additional study by Bartlett and Easterbrooks

(2012) found that first time adolescent mothers who were participants in a prevention home-visiting program and who presented with a history of childhood physical abuse were at an increased risk of neglecting their children. The researchers concluded that this could play a significant role in the perpetuation of an intergenerational cycle of child maltreatment. They proposed future research to focus on best methods for using positive relationships to support resiliency among adolescent mothers with a history of maltreatment aimed at promoting a positive maternal–infant attachment relationship

(Bartlett & Easterbrooks, 2012).

Infant Massage and Research on Touch

Infant massage techniques can promote infant mental health and maternal–infant attachment and provide specific benefits. These benefits include improving the quality of the maternal–infant attachment relationship between the child and primary caregiver, as

well as the social, emotional, psychological, physical, and brain development of the

infant (Bowlby, 1979; Field, 2003; Linden, 2015; Schore, 2012). More specifically,

improvements in the areas of parental depression, as well as more positive caregiving

behaviors and maternal–infant interactions have been found as benefits of infant massage

(Weiss et al., 2000).

Touch is one of the most important and vital components in human development.

Research demonstrates that children will not thrive, or tragically, even live without caring touch (Spitz, 1946). In addition, research on the effects of physical punishment, sometimes the only form of touch that a child receives, has been shown to have negative effects on children, including higher levels of aggression toward parents, siblings, peers, and, later, spouses, as well as becoming more likely to develop antisocial behavior

(Carlson, 2005). According to the Association for Play Therapy (APT; 2015), when children experience touch from a caring caregiver, they begin to develop a sense of self, learn how to relate to others and modulate their affect, and master their own environment.

When touch is appropriately provided, it can promote healing and growth. When touch is

misused, it can impede healthy development and cause harm (Caplan, 2002). Research

also reveals that caring touch releases the calming and connectivity hormone oxytocin

while at the same time decreasing the stress hormone cortisol (Field, 2003).

As noted, adolescent mothers have been shown to be an at-risk population in

regards to the maternal–infant attachment relationship. Although researchers in only one

outcome study looked at utilizing infant massage with this population (Oswalt et al.,

2009), the benefits of infant massage are well documented in the literature (Field, 1998;

Field et al., 2000; Field; 2011; Linden, 2015; Oswalt et al., 2009). Previous research on

infant massage has been focused predominately on the premature infant population, showing positive effects on an infant’s development, the maternal–infant attachment interaction, and the mother’s own psychological well-being (Field, 1998).

Practicing infant massage can assist adolescent mothers in learning how to better read their infants’ cues, which in turn can lead to increased maternal confidence and overall better outcomes for their infants (Weiss et al., 2000). In return, infant massage initiates teaching infants about positive, caring touch and respectful boundaries; it also stimulates the release of oxytocin, which is important for healing and calming (Field,

2003). Research has also shown that adolescent mothers coming from their own background of negative maternal representations can be at higher risk for the transmission of harmful and neglectful interactions with their infants. Fortunately, as

Linden (2015) described, in situations where infants have been neglected and deprived of touch, gentle massage can “reverse the deleterious effects of touch deprivation on infants” (p. 27). Infant massage can reinforce and promote infant mental health while teaching adolescent mothers methods caring, respectful, and even corrective forms of touch (Oswalt et al., 2009).

Summary

An adolescent mother’s maternal–infant attachment relationship is essential for the healthy promotion of secure attachment. The benefits of secure attachment are supported by evidence in the research on a child’s later development (Flaherty & Sadler,

2011). Attachment theory supports the importance of secure attachment as the starting point for greater cognitive, language, and socioemotional development in children

(Dhayanandhan & Bohr, 2016). Adolescent mothers face many factors affecting the

maternal–infant attachment relationship and are considered a high-risk population (Long,

2009). In addition, infants of adolescent mothers are at an increased risk of developing insecure attachment, making it imperative to reach out to this high-risk population and provide appropriate services (Long, 2009). The research discussed shows that it is essential to provide services to assist adolescent mothers in building healthy maternal– infant attachment. Early interventions need to be delivered to support the adolescent mother, to prevent insecure attachment, and to provide positive support of the social, emotional, and psychological wellness of the infant.

Practitioners who work with high-risk populations, such as adolescent mothers, can intervene to provide education and parent training in responsive and nurturing touch to prevent abuse and neglect, or even teach parents corrective forms of touch. As an adjunct model to other parenting programs, FirstPlay® Therapy aims to reinforce and promote infant mental health while teaching adolescent mothers methods of caring and respectful touch (Courtney, 2015). FirstPlay® Therapy can be provided by parents, pediatric nurses, pediatric social workers, school social workers, and clinicians who come into direct contact with adolescent mothers and their infants. The purpose of this study was to explore teaching adolescent mothers how to utilize nurturing touches with their infants to increase the maternal–infant attachment relationship. These caring, respectful, attuned, and joyful activities between the adolescent mother and her infant could build trust and security in the infant and increase maternal–infant attachment that would provide a lifelong impact on the social, emotional, and psychological wellness of that child.

CHAPTER 3

Methods

The purpose of the present study was to implement a one-time pilot pre/posttest study utilizing FirstPlay® Therapy with an adolescent mother–infant dyad population to enhance the maternal–infant attachment relationship and increase levels of comfort with physical touch. This study was predicated on the conceptual underpinnings of attachment theory. Attachment theory supports the importance of secure attachment as the starting point for greater cognitive, language, and socioemotional development in children

(Dhayanandhan & Bohr, 2016). An adolescent mother’s maternal–infant attachment relationship is essential for the healthy promotion of secure attachment. The benefits of secure attachment are supported by evidence in the research on a child’s later development (Flaherty & Sadler, 2011). Research in the areas of maternal influences on the maternal–infant attachment relationship, as well as the underlying foundational theories supporting the intervention, were discussed previously in this proposal.

The methods and procedures for this study are described in this chapter. The sections include the design of the study, study hypotheses, sample characteristics, data collection, recruitment and procedural methods. A description of FirstPlay® Therapy, instruments, and daily log are provided. Finally, data screening and data analysis procedures are described.

Study Design and Hypotheses

The present study was conducted with a one-group pre/posttest design that involved a non-probability, purposive sample. A purposive sample is a nonrepresentative subset of a larger population and is constructed to serve a very specific need or purpose

(Heppner & Heppner, 2004). Additionally, the pre/posttest design allows some studies with an exploratory or descriptive purpose to have considerable value despite having a low degree of internal validity (Rubin & Babbie, 2017). A one-group pre/posttest design established both correlation and time order and therefore had greater value for a pilot study compared to other study designs. This design assessed the outcome variables

(maternal–infant attachment and predisposition to touch) before and after the FirstPlay®

Therapy (Rubin & Babbie, 2017).

Guided by the literature review, the three overarching research questions that guided this study were:

1. Will there be an increase in maternal–infant attachment for adolescent mothers

pre and posttest (2 weeks later) after implementation of FirstPlay® Therapy?

2. Will adolescent mothers have increased positive feelings about physical contact

with their infants 2 weeks after implementation of FirstPlay® Therapy?

3. Will there be a positive correlation between maternal attachment and the

adolescent mothers’ predisposition to touch after participating in FirstPlay®

Therapy?

Guided by the literature review, the three overarching research hypotheses that guided this study were:

1. There will be an increase in maternal–infant attachment of adolescent mothers pre

and posttest (2 weeks later) after implementation of FirstPlay® Therapy. 33

2. Adolescent mothers will have increased positive feelings about physical contact

with their infant 2 weeks after implementation of FirstPlay® Therapy.

3. There will be a positive correlation between maternal attachment and the

adolescent mothers’ predisposition to touch after participating in FirstPlay®

Therapy.

Sample

Participants in this study were adolescent mothers. Adolescent mothers were recruited from three maternity group homes in Palm Beach County, Florida, and one maternity group home in Broward County, Florida. Eligibility requirements for this study were adolescent mothers, ages 18–21 years and their infants, ages 1 month to 12 months.

Eligibility was determined through direct phone contact with the program directors/coordinators of the four group homes. This researcher met individually with eligible adolescent mothers in the group home settings. This researcher introduced the study purpose, the length of adolescent mothers’ involvement in the intervention, risks and benefits, and contact information for this researcher. A purposeful sample of six adolescent mother–infant dyads completed pretest measures. A total of five adolescent mother–infant dyads completed posttest measures.

Sample Recruitment Procedures

Inclusion/Exclusion Criteria

Only adolescent mothers between the ages of 18–21 years and who had their first child were included in this study. The infants were between the ages of 4 weeks to 12 months. The minimum age of 4 weeks was chosen to ensure the healing of the umbilical cord, and the maximum age of 12 months was chosen so that the infants were at a

developmental level at which the mothers could easily apply the intervention techniques.

Adolescent mothers with any prior or active child-welfare involvement as an alleged perpetrator were excluded from the study. This information was obtained by direct report from the group home directors/coordinators, who had previously screened for these criteria. This was also affirmed by the researcher when meeting with the potential participants for the first time. A medical consent form (Appendix E) was completed by the infant’s health care provider/pediatrician to ensure the infant was healthy for infant massage prior to the implementation of FirstPlay® Therapy.

Because adolescents can be a difficult population to maintain in research (Oswalt et al., 2009; Crugnola et al., 2016) several steps were taken to reduce attrition with these participants: Participants had daily contact with their program directors/coordinators, who provided verbal reminders to do the daily massage with their infants. Additionally, a 2- week follow-up for the posttest was scheduled at the time of the intervention, and there was an offer of a $15.00 gift card for completion of the posttest.

Demographic Sample Characteristics

As indicated above, six participants completed baseline measures. Baseline participants ranged in ages from 18–21 years (M = 19.33, SD = 1.03). Infants of the mothers ranged in age from 5 weeks to 40 weeks (M = 13.33, SD = 13.75). Half of the infants were male (n = 3, 50%) and half were female (n = 3, 50%). Half of the participants were African American (n = 3, 50%), and others identified as Hispanic (n =

2, 33.3%) and Other (n = 1, 16.7%). The educational level of the adolescent mothers was evenly distributed with 33% reporting less than a 12th grade education, 33% with a 12th grade education, and 33% with a GED. More than half of the participants identified as

unemployed (n = 4, 66.7%), and the remaining participants were employed part time (n =

2, 33.3%). Lastly, the majority of the participants had not been involved in the child

welfare system as a child (n = 4, 66.7%). The demographic information of the six

participants who completed the baseline measurements can be seen in Table 1.

Data Collection

Approval from the Florida Atlantic University Institutional Review Board was

received before initiating this study. Recruitment began in March 2018, and the

intervention implementation occurred from April 2018 through August 2019.

Intervention Sites

The sample for this study was drawn from four group maternity homes, three in

Palm Beach County and one in Broward County. One group home had a maximum

capacity of 10 beds and took in adolescent mothers up to age 23 years (no minimum age

required). Another group home took in adolescent mothers, ages 18–26 and had a current

total bed capacity of eight. An additional maternity home took in adolescent mothers ages

16–23 and had a total bed capacity of six. The last maternity home took in adolescent

mothers with no minimum age up to age 24 years. However, adolescent mothers under

the age of 18 years lived in a separate cottage. At this group home, there was a total bed

capacity of four for adolescent mothers 18–24 years. For this study, only adolescent

mothers who met the age criteria (age 18–21 years old) were used.

These group homes offered support to parenting adolescent mothers and their infants. Examples of resources available at these group homes included, but were not limited to, case management, parenting courses, individual counseling, advocacy support, health education, opportunities to attend school, vocational training, employment and

mentorship services, life skills, and spiritual support. Adolescent mothers who attended these group homes met certain criteria, which is specified below, in order to become residents. These group homes were under the daily supervision of a case coordinator, a resident program director, or a program coordinator. Case coordinators, program directors, and program coordinators provided similar services, such as engaging with and facilitating case management of the adolescent mothers and their babies, assisting the mothers make doctor appointments, and making sure the mothers followed through with the program guidelines and procedures. All coordinators/directors had daily interactions with the adolescent mothers in the group home setting.

Adolescent mothers who resided in the first group home were up to age 23 (no minimum age). These adolescent mothers had to meet the following criteria to reside in the group home: pregnant, passing a drug test, and background screening. If the mothers had other children, those other children were required to live off campus. Some of the adolescent mothers ages 18 and older might have had current involvement with state child protection agencies, however they were not eligible for participation in this study.

Adolescent mothers in the group homes must have either been attending school full time or working part time or full time. As of 2018, all of the referrals into this residential program have come from another agency (50%) or the internet (50%). In regards to race,

80% of residents have been African American, 15% Haitian, and 5% Caucasian.

Adolescent mothers at this group home could stay from 6 months up to 1 year.

Adolescent mothers living at the second group home were between the ages of

18–26, with a first-time pregnancy. If they had other children, those children must have been in the care or custody of someone else. The mother must have completed a physical

exam and tuberculosis test, and if they had a history of substance abuse, they must have

had at least 6 months sober living with the support of an active sponsor. They could not

have an active/open case with the state child-welfare agency or any active/open warrants to reside in this group home. According to the resident program director, a large percentage of the adolescent mothers who attended the program had a lack of familial support. In addition, they might have also had a history of domestic violence from either their own family members or the baby’s biological father. Almost all of the referrals into this residential program came from the internet (98%), with a small percentage (2%) coming either from a referral helpline, another agency, or a nurse, doctor, or word of mouth. As reported by the program director, in 2018, adolescent mothers who completed the group home program at this location were 25% African American, 25% Hispanic

American, 25% Caucasian, and 25% Haitian. Here, the adolescent mothers could stay in the program for up to 2 years and must be re-assessed every 3 months for compliance with group home rules.

Adolescent mothers residing at the third group home were between the ages of

16–23 years. If the adolescent mothers had other children, those children must have lived off campus. After completing the admission process, adolescent mothers underwent a physical exam, and drug testing was only done if the staff believed there might be drug use. Adolescent mothers were permitted to live in the group home if they had open child- protective services cases, but again were not eligible to participate in this study.

Adolescent mothers must have been attending school or working full time while residing at this group home. Almost all the referrals to this residential program were from the internet (70%), or word of mouth, a referral hotline, a local child welfare agency, or other

maternity homes (30%). As of 2018, 80% of the residents were African American, 15%

Caucasian, and 5% Hispanic American and/or Haitian. This group home allowed for adolescent mothers to stay in the program 1–2 years.

Adolescent mothers in the fourth group home were between the ages of 18–24 years. There was no minimum age required by the agency, but adolescent mothers younger than age 18 were housed in separate cottages. This facility served first-time pregnant adolescent mothers as well as adolescent mothers who might have a child in the foster care system. It was overseen by a program director. Adolescent mothers must have been working full time or attending school while a resident in the group home. Referrals for the home came from the local child-welfare agency or the community. As reported by the program director, in 2018, 80% of the residents were African American, 10%

Caucasian, and 5% Hispanic American, and/or Haitian. Adolescent mothers could stay in

the program at this group home for any length of time up until they reached age 25 years.

Informed Consent Processes

As part of the informed-consent process, this researcher met directly with eligible adolescent mothers at the group homes to discuss the intervention, benefits, risks, stipend, and time involvement. This researcher collected the signed parental consent forms

(Appendix F), explained and completed the demographic questionnaire with individual participants (Appendix C), disbursed the medical consent forms to eligible participants

(Appendix E), and confirmed the inclusion criteria. In addition, this researcher, who was certified in FirstPlay® Therapy, discussed the importance and benefits of the study during the informed consent process. That discussion included describing infant massage and the research supporting brain development and increased parent–child attachment

through the fun time of infant massage as well as intimacy with their infant. It was explained that caring touch releases the calming hormone of oxytocin, lowers the stress hormone cortisol, and assists with digestion and bowel elimination (Field, 2011; Field et al., 2004). Further, the participants were informed that with the modality of infant massage, infants learn caring, positive, and respectful touch and personal boundaries while they are taught the sensation of relaxation and encouraged toward deeper and more sound sleep (Courtney et al., 2017).

Implementation

Baseline assessment measures were administered by this researcher 1 week prior to the intervention. Immediately after completing the intervention, which was administered by this researcher, the daily log was explained to the participants. This researcher provided instructions for the daily log to be filled out every day for 14 days, beginning the day after the intervention. In addition, a date was scheduled for 2 weeks after the intervention to administer the posttest by this researcher. The daily log was collected along with the follow-up posttest assessments by this researcher on that date.

The Certified FirstPlay® Practitioner (researcher) was available for questions throughout the teaching of the intervention. If, during the 2-week period when participants completed the daily infant massage, the participant felt the intervention was causing discomfort to the infant, she could immediately contact her group home coordinator/director, who could follow up with the pediatrician. If the participant forgot how to implement the intervention, she could refer to her manual or she could contact the researcher by phone or email. For participants in the study, there may also have been some stress involved specific to questions about attachment. If needed, the researcher

could refer participants to the group home/coordinator who could make outside referrals.

In the event that a participant experienced emotional issues during the teaching of the intervention, outside referrals were available by this researcher. In addition, the group home coordinator/director was available to assist the participants with outside referrals, if needed. During this study, no referrals were needed, and no participants asked for additional assistance by either phone or email.

Intervention

FirstPlay® Therapy Infant Storytelling-Massage (FirstPlay® Therapy)

This study was conducted using the FirstPlay Parent Manual developed by Janet

Courtney (2015). She developed FirstPlay® Therapy after 30 years of clinical practice in the area of developmental play therapy and training in Ericksonian based storytelling

(Baldwin et al., 2020; Courtney et al., 2017). The FirstPlay Parent Manual (Courtney,

2015) was developed to support the instructional process with parents conducted by the

Certified FirstPlay® Practitioners. The FirstPlay Parent Manual consists of two components. The first part of the book contains important information that parents need to understand prior to engaging in the storytelling-massage with their infants. This includes understanding an infant’s readiness cues, such as smiling, a relaxed body, the infant’s body is relaxed, cooing, direct eye contact, and brightening of the infant’s face.

By contrast, an infant’s cues of not being ready would be the turning away of the head, flailing arms, fussiness, hiccups, arching back, and/or crying. The second part of the book comprises an original story called “The Baby Tree Hug” (Courtney, 2015) that includes massage and first-play type activities that support parent–infant bonding and the attachment relationship.

The intervention was conducted by the researcher, a certified FirstPlay®

Practitioner since 2016 who has received 36 hours of certification training. This certification involved completing an in-training exam, presenting case studies during the first year, and individual case supervision/consultations specific to FirstPlay® Therapy.

The researcher has also assisted with biannual trainings involving volunteer mothers ages

21 and younger. These trainings included multidisciplinary professionals such as nurses, massage therapists, and clinicians. The FirstPlay® Practitioner (researcher) is certified to teach and utilize this technique as a therapeutic intervention in practice with adolescent mothers and their infants. This researcher met a level of competency in the foundations and methods of FirstPlay® Therapy provided through the FirstPlay Practitioner Manual

(Courtney, 2014) and taught by a FirstPlay® Therapy Instructor. This certification allowed any FirstPlay® Practitioner to utilize this technique as a therapeutic intervention in practice with adolescent mothers and their infants.

A limitation to most infant massage research studies is the lack of or limited explanation about the particular infant massage curricula and protocols (Oswalt &

Biasini, 2011). The current study provided adolescent mothers with a the FirstPlay

Parent Manual (Courtney, 2015). This parent manual was designed to address all of the important issues for caregivers to be aware of when practicing this massage thereby decreasing potential risks to the infant. The manual demonstrates techniques through simple instructions and illustrated pictures of infant massage strokes that are easy for the parent and safe for young infants. Adolescent mothers learned how to provide playful, caring, respectful, and nurturing touch by the certified FirstPlay® Therapy Practitioner

(researcher) to their infants. In addition, storytelling component of “The Baby Tree Hug”

(Courtney, 2015) offered indirect, positive messages embedded in the story. With

FirstPlay® Therapy, adolescent mothers tell the story as they simultaneously connect

with their infants through the story and infant massage. The parent manual was given to

the adolescent mothers to keep as a reference. The FirstPlay® Practitioner (researcher)

acted as trainer, coach, and supervisor who guided the adolescent mother in conducting a

FirstPlay® Infant Storytelling-Massage session. The FirstPlay® Practitioner did not

touch the child, but rather educated and demonstrated to the adolescent mother on a baby

doll the interactive storytelling techniques as provided in the FirstPlay Parent Manual

(Courtney, 2015). While the researcher demonstrated the techniques on a doll, the

adolescent mother simultaneously practiced the infant massage storytelling techniques on

her own infant.

The review of the FirstPlay®Therapy guidelines took approximately 15-20

minutes, and the FirstPlay®Therapy demonstration took approximately 30 minutes. In

addition, participants were asked to implement the FirstPlay® Therapy techniques on a daily basis with their infants and to record their interactions with their infants in a daily log for 2 weeks.

Implementation Details of FirstPlay® Therapy (Daily Log)

Four of the participants returned their daily logs at the end of the 2-week implementation period. Participant three did not return her daily log after the implementation period. The average length of time for daily massages for week one was

20.57 minutes. The average length of time for daily massages for week two was 17.85 minutes. The average length of time of daily massages for the 14 days was 19.21 minutes.

The following parts of the body that were cited most frequently for the four participants

who completed the daily massage included feet (n = 4), legs (n = 4), arms (n = 4), hands

(n = 3), face (n = 3), and head (n = 3). Only one person massaged their infant’s stomach.

Adolescent mothers were asked not to massage their infants 72 hours after immunizations, therefore some logs reflected days of no massage due to immunizations.

The following participants missed the daily log due to immunizations: participant one

missed 3 days, and participant four missed 2 days. The following amount of days not

recorded for massages in the 14-day period due to noncompliance were as follows: for participant one, 9 days were missed, participant two missed 5 days, participant five missed no days, and participant six missed 2 days. The average number of days completed for all participants was 10 days. Lastly, all massages occurred in the mothers’ bedrooms (n = 4).

Risk minimization

This model was an intervention for physically healthy infants and was commenced only after the adolescent mother consulted with her infant’s health care provider/pediatrician. Adolescent mothers were also screened prior to the intervention by the group home coordinator/director for the exclusion criteria of no current child-welfare involvement to further reduce risk. Additionally, because the researcher was trained in the ethical standards of touch, and because she did not touch or massage the infants themselves, she did not need to be a licensed massage therapist to teach the techniques of

FirstPlay® massage methods to adolescent mothers (Courtney, 2015). However, a licensed massage therapist was present during the teaching of FirstPlay® to provide further instruction as participants learned the intervention. The licensed massage therapist and FirstPlay® instructor guided the mothers to use gentle, soothing touch to diminish

the risk of harm to the infant. Participants went over a Parent Checklist (Appendix G) that

outlined additional safety precautions prior to starting the intervention. This researcher

discussed with the participant the need to “ask their baby’s permission for the massage.”

Prior to massaging the infant, participants were instructed to show their hands above the baby’s face, and ask in an excited voice if they wanted a massage.

Instruments

Four instruments were used in this study: the demographic questionnaire

(Appendix A), the Maternal Attachment Inventory (MAI; Muller, 1994; Appendix B), the

Physical Contact Assessment Questionnaire (PCAQ; Weiss, 2000; Appendix C), and the

Daily Log (Appendix D).

Demographic Questionnaire

Demographic information for the sample was obtained using a self-report

questionnaire developed by this researcher to include age of the mother, age and sex of

her infant, race of the mother, highest level of education, employment status (FT/PT), and history of child-welfare or foster-care involvement as a child (see Appendix A).

Maternal Attachment Inventory

The Maternal Attachment Inventory (MAI; Muller, 1994) was administered as a

pretest, posttest scale to assess the adolescent maternal–infant attachment relationship.

The MAI is a 26-item instrument that measures mother to infant attachment feelings. This

self-report instrument uses a 4-point Likert scale as follows: 4 = almost always, 3 = often,

2 = sometimes, and 1 = almost never. All items of scores are then summed for a possible

total score of 104. Higher scores reflect higher maternal attachment feeling toward the

infant.

Items for the MAI were obtained through review of the attachment and maternal

adaptation literature (Muller, 1994). Fifty-one items were identified and submitted to a group of 12 experts to quantify construct validity (Muller et al., 1993). This panel consisted of theoreticians, postpartum and neonatal nurses, and women with young infants. Each expert panel scored each item according to its relevance to maternal affectionate attachment: 1 = not relevant; 2 = much revision needed, hard to assess relevance; 3 = needs minor revision; 4 = relevant (Muller et al, 1993). Because more than two experts evaluated the validity of proposed items, a content validity index was not computed. The final instrument contains 26 items.

The instrument was initially tested with a sample of 196 women at 1 month postpartum (Muller, 1996). The internal consistency of this original version was α = 0.85

- 4-week babies, α = 0.76 - 4-month babies, and α = 0.85 - 8-month babies. Cronbach’s alpha coefficient was .85 (Muller, 1996). Other studies have also supported its internal consistency. Shin and Kim (2007) obtained a Cronbach’s alpha of 0.85. Chen and colleagues (2013) utilized a Chinese version of the MAI (CMAI) and found the CMAI to be a reliable and valid measure of the early stages of maternal–infant attachment.

The MAI has limited use in an adolescent population. One dissertation that used the MAI with an adolescent population was a pilot study of 10 adolescent mothers between the ages of 11–20 years and found a Cronbach’s alpha of .88 pretest and . 98 posttest in the study sample (Harrison, 2011). No other studies have been identified that use the MAI with an adolescent population.

Physical Contact Assessment Questionnaire

The Physical Contact Assessment Questionnaire (PCAQ) was administered as a

pre/posttest scale to measure a mother’s predisposition toward touch (Weiss et al., 2000).

The PCAQ consists of three sections with a total of 24 questions that address an

individual’s thoughts and feelings about physical contact with others during three

different time periods: one’s ongoing life (Attitudes Toward Touch), childhood (Felt

Security Regarding Current Tactile Experience), and current relationships with family

and friends (Felt Security Regarding Current Tactile Experience). Each section of the

scale was scored separately, because the three sections measure very different aspects of

the profile (Weiss et al., 2000). For this study, a scale score was created by totaling

subscale I and subscale III. Subscale II was not included in this study, because the

purpose of the study was not focused on an individual’s touch experiences as a child.

The first subscale, Attitudes Toward Touch, was used to assess individuals’ attitudes toward touch overall. This subscale included 10 items, with each item scored on

a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). This scale

assesses general responses to touch, with higher scores indicating greater receptivity to

touch. Statements such as “I appreciate a hug when I need comforting” and “I am

comfortable putting my arm around a friend’s shoulder” are used to assess comfort with

touch as part of one’s ongoing life. Numbers circled for each of the ten questions were

summed to yield the score for this section. However, items 3, 4, 7, 8, & 10 were reversed

in the scoring process (a response of 1 receives a score of 4). Possible subscale scores

ranged from 10 to 40, with higher scores indicating a more positive view about the value of touch in the individual’s life.

The third subscale, An Individual’s Felt Security Regarding the Touch she/he currently receives from Significant Others, was used to assess individuals’ felt security regarding the touch they currently received from significant others. This subscale included 8 items, with each item scored on a 4-point Likert scale ranging from 1 (never) to 4 (much of the time). Questions about touch in current relationships included “how often are you hugged, kissed, or caressed by your friends and family” and “to what extent does the touch you receive from friends and family provide a supportive sense of security in your life?” Items 25 and 26 were not included in the score as they contained a qualitative component. The scores for all other items were summed after reversing the score for item 20. Possible subscale scores ranged from 6 to 24, with higher scores indicating greater felt security regarding the touch currently received from family and friends (Weiss et al., 2000).

For the purposes of this study, responses from the Attitudes Toward Touch

(subscale I) and An Individual’s Felt Security Regarding the Touch she/he currently received from Significant Others (subscale III) were used to determine the effects of the intervention on feelings about physical contact. For both subscales, higher scores indicated more positive experiences and higher comfort with physical contact.

Internal reliability of the three subscales ranged from 0.83 to 0.89 (Weiss &

Goebel, 2003; Weiss & Wilson, 2006; Weiss et al., 2000). Correlations among the subscales have also been found: attitudes toward touch (subscale I) are associated with felt security in current tactile relationships (subscale III; Weiss et al., 2000). In previous research, mothers who reported themselves as less comfortable with being touched were

significantly more likely to have neonates who were physiologically and behaviorally more hypersensitive and aversive to touch at birth (Weiss & Wilson, 2006).

It must be noted that a literature review found only one study that utilized this measure with an adolescent population (Oswalt et al., 2009). Although this instrument has not been normed for an adolescent population, it has been utilized in the area of infant massage research (Oswalt & Biasini, 2011; Weiss et al., 2001).

Daily Log

Participants were asked to implement the FirstPlay® Therapy techniques on a daily basis and to record their interactions with their infants in a daily log for 2 weeks in order to examine the amount of time the adolescent mothers were actually implementing

FirstPlay® Therapy. This researcher explained how to record information in the 14-day daily log handout for implementation of infant massage-storytelling. Each participant was asked to keep a daily log to include the following: time of day when massage was administered, location in the residence where the massage was administered, parts of body massaged, and length of massage in minutes. Four out of the five participants who completed the pre and posttest questionnaires also completed the daily log. Of the other two participants, one did not return the daily log and one participant only completed the pretest questionnaire.

Data Analysis

The researcher entered the collected data into SPSS and checked for data entry errors before beginning the analysis. Then, a frequency analysis was performed to examine any missing data. Out of the six participants whose data were included in analyses, one participant had missing data across one of the pretest subscale measures

(Section III of the PCAQ), and one participant did not return the 14-day daily log. In addition, one participant completed the pretest; however, this participant left the group home prior to the administration of the posttest, and thus her data was not included as part of the paired sample t-test.

First, descriptive statistics were run for each variable. Then bivariate correlational analyses were conducted on continuous demographic and outcome variables to examine if there were any statistically significant relationships. The following demographic variables were included in the correlational analyses: age of the mother, age of the infant, gender of the infant, race of the mother, mother’s highest level of education, mother’s current employment status, and mothers’ history of child-welfare involvement as a child.

In addition, total pre and posttest scores for the outcome variables of maternal attachment and physical contact were included in the correlation analyses as well as the continuous data from 14-day daily log, which included daily massage in minutes and total daily massage in minutes for the 14-day implementation. These correlations analyses were conducted to assess for any relationship between these different variables. A regression analysis was performed on one significant correlation, gender of the infant, in order to further understand its relationship to the outcome variable of the PCAQ. Cross tabulations were presented to show the patterns between nominal demographic variables.

A regression analysis was performed on one significant correlation, gender of the infant, in order to further understand its relationship to the outcome variable of the PCAQ.

Additionally, Chi-square analyses were conducted to assess for significance in these patterns. T-tests were also performed to assess any differences between the pretest and posttest measures.

CHAPTER 4

Results

In this section the findings of the study are presented. First, results from the

correlations analyses are presented. Results from the regression analysis on one

significant correlation are presented. Next, results from the cross tabulations between

demographic variables are presented. In addition, chi-square results for two demographic variables are presented. To address the research questions, total pre and posttest scores

for the outcome variables of maternal attachment and physical contact are presented.

Bivariate Correlations

Correlational analyses indicated significant relationships between several of the

demographic and outcome variables (see Table 2). A significant correlation existed

between the mother’s age and the age of her infant (r = .850, p < .05): the older the

mother, the older her infant was in this study. A negative relationship was found between

the mother’s age and her employment status (r = -.875, p < .05). The older the mother,

the more likely she was to be unemployed. Furthermore, there was a negative relationship

between a mother’s age and her history of child welfare (r = -.875, p <.05): the older the

mother, the less likely she was to have a history of child welfare. In addition, there was a

positive correlation between the mother’s employment status and her welfare history (r =

1.000, p < .01). The more likely a mother was to be employed, the more likely she was to

have a child-welfare history. There was a negative correlation between an infant’s age,

mother’s employment status and child-welfare history, (r = -.826, p < .05 and r = -826, p

< .05), and adolescent mothers with older children were less likely to be employed and less likely to have a history of child-welfare involvement as a child.

Regarding significant correlations between the demographic variables and the implementation variables gained from the daily log, positive relationships were found. A positive relationship existed between a mother’s employment and average time of daily massage in minutes (r = .962, p < .05): if a mother was employed, generally more time was spent massaging her infant. A positive relationship also existed between a mother’s child-welfare history and average time of daily massages in minutes (r = .962, p < .05): if a mother had a history of child welfare involvement as a child, more time was spent massaging her infant.

Correlations analyses between some of the demographic and implementation variables and the outcome variables (maternal attachment and predisposition to touch), presented significant relationships. For the Physical Contact Assessment Questionnaire

(PCAQ), a significant correlation included a positive relationship between gender of the infant and PCAQ posttest (r = .880, p < .05), whereby mothers with female infants had higher scores on the PCAQ posttest. A negative relationship existed between the average number of daily massages in minutes and the PCAQ posttest (r = -.986, p < .05): the more time spent massaging her infant, the lower the mother’s score on the PCAQ posttest. While there was a significant correlation between pre and posttest scores on the

Maternal Attachment Inventory (MAI; r = .887, p < .05), pre and posttest scores of the

PCAQ showed no significant correlation (r = -.592, p < .05). Lastly, bivariate correlations were conducted to assess if participants’ scores on each outcome variable

(maternal attachment and predisposition to touch) showed a relationship to each other

after completing the FirstPlay® Therapy. The results showed no significant relationship

(r = .116, p >.05) at posttest. Thus, it could be concluded that maternal attachment and

physical contact were not correlated after the intervention.

Regression

To provide further analysis on the significant correlation between the categorical

variable, gender of infant, and continuous outcome variable, Total PCAQ score, a linear

regression analysis was performed to test if the gender of infant (independent variable)

predicted the Total PCAQ score (dependent variable). The results of the regression

indicated that gender explained 77.4% of the variance (R2 =.774, F(1, 3) = 10.25, p <

.05). It was found that gender significantly predicted the PCAQ total score (β = .880, p <

.05), with mothers of female infants more likely to have higher scores on the PCAQ.

Cross Tabulations and Chi Square Analyses

Because several of the significant correlations discussed suggested potential patterns across the nominal variables, cross tabulations were performed. The cross tabulations of the demographic variables that were significantly correlated are presented in Table 3 and Table 4. To further determine if these demographic variables were associated, a chi-square analysis was performed. Chi-square statistics were calculated to determine if there was a significant pattern in the relationship between demographic variables of age of the mother and age of the infant (see Table 3). The results showed a significant relationship between the two variables X2 (9, N = 6) = 18.00, p < .05. There

was an association between the variables age of the mother and age of the infant. In

addition, a chi-square test was run to examine the association between a mother’s history

of child welfare and her employment status (see Table 4). The results showed a significant relationship between the two variables X2 (1, N = 6) = 6.00, p < 0.01. There was an association between the variables of a mother’s history of child welfare and her employment status.

Paired sample t-tests

For the participants who completed posttest measures (N = 5), scores were assessed on each outcome variable to see if they differed after completing FirstPlay®

Therapy. Two paired sample t-tests were conducted for maternal attachment and predisposition to touch. The results for these analyses are shown in Table 5. Paired sample t-tests revealed no significant difference in an adolescent mother’s maternal attachment relationship between pretest (M = 32.6, SD = 6.80) and posttest (M = 32.2,

SD = 9.49), t (4) = .192, p = .857. In addition, the paired sample t-test revealed no significant differences in a mother’s predisposition to touch between pretest (M = 41.5,

SD = 2.38) and posttest (M = 40.25, SD = 9.84), t (3) = .271, p = .804.

CHAPTER 5

Discussion and Implications

The present study examined the effect of an adjunctive play therapy model called

FirstPlay® Therapy on maternal attachment and comfort with physical touch. The study’s primary objectives were (1) to examine the preliminary effects of FirstPlay® Therapy on the maternal–infant attachment relationship of adolescent mother–infant dyads, (2) to examine the preliminary effects of FirstPlay® Therapy on an adolescent mother’s predisposition to touch, and (3) to determine if there is a relationship between the maternal–infant attachment relationship and the adolescent mother’s predisposition to touch. Overall, the findings of FirstPlay® Therapy resulted in non-significant increases in participants’ maternal–attachment relationship and predisposition to touch after the intervention.

In this chapter, a discussion of the findings related to each hypothesis will be presented. Then several limitations to the methodology of the study will be discussed.

Lastly, implications for practice and future research will be discussed.

Hypothesis 1

For the study’s first hypothesis, it was expected that there would be an increase in maternal–infant attachment of adolescent mothers 2 weeks after the implementation of

FirstPlay® Therapy. This hypothesis was not supported. One explanation for these results 55

could be that the length of this study was insufficient to reveal changes in the maternal-

attachment relationship. Research has suggested that maternal attachment is a

phenomenon that may need time to develop as the mother learns new positive ways to

interact and engage with her infant and as the role of motherhood evolves over time

(Muller, 1994). Harrison (2011) found that after a 4-week educational intervention called

Baby Basics, although no statistically significant changes in maternal attachment were

found, there was a small increase in maternal attachment for adolescent mothers

participating in educational parenting classes. These researchers suggested increasing the

time between pre and posttest measures to fully assess the extent of the maternal-

attachment relationship. The current study explored maternal attachment after a one-time

intervention using a 2-week daily log, which may have not been enough time to see a change in maternal attachment for adolescent mothers. While increases in maternal attachment were not evident within the scope of this study’s data collection, it is possible that as adolescent mothers begin to integrate the skills from FirstPlay® Therapy, their maternal attachment may shift over time.

Hypothesis 2

For the second hypothesis in this study, it was expected there would be an increase in positive feelings about physical contact for adolescent mothers toward their infants 2 weeks after the implementation of FirstPlay® Therapy. This hypothesis was not supported. These results were somewhat surprising given the results of a study conducted by Oswalt et al. (2009), which found that adolescent mothers reported significantly increased levels of positive feelings associated with touching their infants after a massage intervention. However, the Oswalt et al. (2009) study implemented the infant massage

intervention for a 2-month period, which may have allowed more time for a measurable

change in the adolescent mothers’ responses to a massage intervention.

Again, although there was no statistical significance for this hypothesis, there

were some significant relationships that could warrant further discussion. Regarding the

outcome variable for touch, this study found three significant relationships between the

PCAQ scale and the following demographic characteristics: mothers’ employment, mothers’ history of child welfare, and gender of the infant. In addition, there was a

significant negative relationship found between the PCAQ and the daily log.

Physical Contact and Mothers’ Employment

In this study, adolescent mothers who were employed part time scored higher on

the PCAQ than those who were unemployed, indicating that those who worked felt more

comfortable with touch.. There is currently no research in the area of an adolescent

mother’s employment and comfort of touch with her infant. Current research in the area

of adolescent mothers compared to adolescent non-mothers has found that adolescent

mothers were at a higher risk for unemployment, which in turn has been linked to a risk

of physical child abuse with their children (Afifi, 2007). However, research has shown

that when adolescent mothers are provided safe and nurturing living situations, this can

support them in attaining education and finding employment, which can lead to more

engaged parenting and attachment (Hudgins et al., 2014). These various forms of support

may have assisted the adolescent mothers in this study to feel more comfortable in

providing appropriate touch to their infants. The group homes provided safe and

supportive environments that included assistance finding employment, which may have

influenced adolescent mothers’ ability to learn and practice the infant massage.

Physical Contact and Mothers’ History of Child Welfare

Adolescent mothers in this study who had a history of child-welfare involvement

as a child scored higher on the PCAQ, indicating a higher level of comfort with touch.

This was an interesting finding, because previous research in the area of adolescent

mothers and child welfare has found that adolescent mothers are often unaware of the

emotional needs of their infants, and are more likely to be victims of child abuse and

neglect than older mothers (Font, et al., 2019; Ng & Kaye, 2013). For this study, the

group home setting provided many supportive services including counseling, parenting

classes, and religious services. It may be that adolescent mothers were given the

opportunity to participate in counseling, individual therapy, and parenting skills. These

opportunities might have assisted adolescent mothers in becoming more cognizant of

their own upbringings, thereby making them more open to learning new and positive ways to interact with their own infants that they may not have experienced otherwise. As

such, the adolescent mother participants were able to feel more comfortable with the

physical contact as part of this intervention study.

Physical Contact and Gender of the Infant

Mothers with female infants scored higher on the PCAQ in this study, again meaning that those with female infants reported being more comfortable touching their infants. Only one other study in the literature has utilized the PCAQ to assess adolescent mothers’ comfort with touch (Oswalt et al., 2009). However, these researchers did not state any significant findings specific to gender of the infants and the PCAQ (Oswalt et al., 2009). The relationship between scores on the PCAQ and gender of the infant found

in the current study could indicate that adolescent mothers believe it is more gender

appropriate to touch and massage their female infants as opposed to a male infant. These findings warrant further exploration.

Physical Contact Reported in the Daily Log

Lastly, in this study, adolescent mothers were asked to keep a 14-day daily log for this researcher to monitor the frequency and implementation of FirstPlay® Therapy.

Analysis of the logs found a negative relationship between the score on the PCAQ and the amount of daily massage. That is, adolescent mothers who scored lower on the PCAQ

(i.e., less comfortable with touch) recorded massaging their infants more frequently.

However, it is difficult to assess the accuracy of the log, because daily massages were not supervised and were completed by self-report. Therefore, adolescent mothers in the study may have recorded massaging their infants without actual implementation of the intervention. This data should be expanded on, with possible monitoring of the daily massage by staff members in order to further examine the implementation of a daily log and its possible relationship to physical touch.

Hypothesis 3

For the third hypothesis in this study, it was expected that there would be a positive correlation between maternal attachment and the adolescent mothers’ predisposition to touch 2 weeks after the implementation of FirstPlay® Therapy. This hypothesis was not supported. These non-significant results may be most easily explained by the small sample size, as existing literature suggested that there should have been a significant relationship between the variables.

Several studies indicate that comfort with touch is interrelated with a parent’s attachment to their child (Field et al., 1996; Goodman & Santangelo, 2011; Roberts &

Glover, 2008). However, only two known studies with an adolescent population have

examined these variables separately and found a positive correlation for maternal

attachment and increased positive and comfortable feelings about physical contact

(Harrison, 2011; Oswalt et al., 2009). In addition, a study by Cinar (2014) found

statistically significant increases in maternal attachment after an 8-week baby education

intervention that included infant massage as part of its curriculum. Although touch was

not measured, the implementation of infant massage for the Cinar (2014) study possibly

could have influenced maternal attachment. Future studies could continue to examine

these variables by increasing the number of interventions as well as increase long-term follow-up to assess maternal attachment and predisposition to touch.

Limitations

Although the study adds to the current literature as a pilot study on adolescent mothers, maternal attachment, and a mother’s predisposition to touch, as with all studies, it has several limitations. The first limitation of this study was the small sample size (N =

5), which eliminated the possibility of statistical significance because of a lack of power.

In addition, the small sample size, with its majority of African American respondents currently in the group home settings, also limits the study’s generalizability.

The short length of the intervention also constitutes a limitation. Two weeks may not have been enough time to measure change in maternal attachment or feelings regarding physical touch from pre to posttest. Researchers who have conducted attachment interventions have used more time between pre and posttest data collection.

Oswalt (2009), Harrison (2011), and Mayers (2008) all implemented their interventions during time frames of between 4 weeks and 2 months. Each of these studies found

increases in both maternal–infant attachment (Harrison, 2011; Mayers, 2008) and enhanced maternal–infant physical contact between adolescent mothers and their infants

(Oswalt, 2009).

Another limitation is that a non-probability convenience sampling was utilized to allow this researcher to select accessible participants in a group maternity home setting with no randomization and no control group. This type of sampling limited the study’s external validity, and the findings may only be applicable to the participants in this study.

Additionally, the lack of a control group made it difficult to evaluate the effect of extraneous variables that could have influenced the results (Rubin & Babbie, 2017).

Threats to internal validity for this study may have included the group home setting itself, where support was available in the areas of life skills, parenting courses, and counseling. Other possible influential factors could have been that daycare assistance was provided to the adolescent mothers and that group home staff members helped the women find jobs. A control group could have provided a comparison for extraneous variables, thereby possibly increasing reliability for this study. Future studies could implement a control group to rule out any confounding variables and to increase the statistical validity of the results.

A third limitation of this study was the use of self-report (Rubin & Babbie, 2017).

Self-reporting may have encouraged social desirability, especially because the researcher was also the facilitator. This created an inherent conflict, given the dual role of the researcher, in which the participants may have felt pressured to respond to the questionnaires in a way that would meet the researcher’s expectations. Rubin and Babbie

(2017, p. 265) refer to this as “research reactivity,” which can be defined as ways that researchers might prejudice research outcomes by their presence.

Another limitation is that although the instruments used in this study exhibited appropriate levels of reliability and validity in previous research, there has been limited use of these measures with an adolescent population. Both the PCAQ (Oswalt et al.,

2009), and the MAI (Harrison, 2011) have only been used in two studies with an adolescent population. Although the PCAQ has been utilized in the area of infant massage (Oswalt & Biasini, 2011; Weiss et al., 2001), it has only been normed with an adolescent population in one other study (Oswalt, 2009). Therefore, the scale may have been difficult for adolescent mothers to understand, even though the researcher stated she would provide clarity if needed.

A final limitation of this study was that it did not include numerous factors that have been shown to influence maternal attachment or feelings related to touch. For example, the roles of ethnicity and social class were not examined. In addition, while participants were asked to report on child-welfare involvement as a young person, an adolescent mother’s history of physical or sexual abuse, which can also affect maternal attachment and feelings about touch (Bartlett & Easterbrooks, 2012), was explicitly assessed. Other factors that were not accounted for were the support of family of origin or the family of the partner (Kumar et al., 2018), the presence of postpartum depression

(Larson, 2004), parental stress in the adolescent mother (Malone, 2006; Nicolson et al.,

2013), or the temperament of the infant on the mother–infant interaction (Crugnola et al.,

2016; Nicolson et al., 2013; Oswalt et al., 2009).

Implications for Future Research

There are several research implications to the current study that could be further

expanded on. These implications include increased time between pre and posttest data

collection, sample size, randomization of the sample, measurement tools, implementation

of the daily log, and a need for a qualitative component.

Expansion of data collection

Due to the short interval between pre and posttest data collection, it is still unclear

if there could be positive changes in an adolescent mothers’ maternal attachment and

predisposition to touch. Recent meta-analyses have demonstrated that intervention programs that provide increased interventions over a longer period of time are twice as

effective as programs with less frequent interventions (Geerhart et al., 2004; Nievar et al.,

2010). Future studies should consider a longitudinal design with several collection points

and multiple implementations of interventions to determine any changes in maternal

attachment and touch over time.

Sample Size

It is also worth reiterating that the sample size of 5 participants is consistent with

other studies utilizing an adolescent population, because historically it has been difficult

to retain adolescents for studies (Harrison, 2011; Oswalt et al., 2009). For this study,

although the participants were recruited from four group maternity homes, the inclusion

criteria specified an age restriction of 18 to 21 years old, making it difficult to obtain a

larger sample. However, there are additional studies with adolescent mothers in which

researchers have been able to implement their interventions with larger sample sizes by

including adolescent mothers younger than age 18 years (Bartlett & Easterbrooks, 2012;

Crugnola et al., 2016; Hudgins et al., 2014; Nicolson et al., 2013; Malone, 2006; Mayers

et al., 2008). The current study could be replicated to increase the sample size, as two of

the group homes had adolescent mothers younger than 18 years. Another challenge with

the inclusion criteria for this study was the high turnover rate in these group home

settings. Several adolescent mothers who scheduled to complete the intervention left the

group home prior to the study’s implementation. Future studies could also expand the sample criteria to include adolescent mothers in community settings such as schools, mentoring programs, or independent living homes to obtain larger sample sizes.

Randomization of Sample

The current study could have been strengthened with randomization of the sample. Randomizing a sample allows for a more equal chance for participants to be selected for the intervention (Rubin & Babbie, 2017). It also reduces researcher bias and is more reflective of the entire population of adolescent mothers. Although the small sample size greatly limited the possibility of randomization in this study, future studies could implement randomization of samples from each group home in order to provide a clearer representation of adolescent mothers in group home settings.

Measurement Tools

The MAI has only been normed in one other study examining an adolescent population (Oswalt et al., 2009). Therefore, it might be beneficial to utilize an additional measure when examining maternal attachment that has been normed with an adolescent mother population, such as the Parental Bonding Instrument (PBI; Black Dog Institute, 64

2011). Regarding a mother’s attachment dimensions, the Experiences with Close

Relationships (ECR, Fraley et al., 2000) could be utilized. In addition, future studies could incorporate additional measurement tools to assess for such factors as postpartum depression (BDI-II; Beck et al., 1996), parental stress (PSI; Abidin, 1995), temperament of the infant (EITQ; Medoff-Cooper et al., 1993), the adolescent mothers Adverse

Childhood Event score (ACE; Dube et al., 2003), and tactile experiences between the infant and caregiver with the Parent-Infant Caregiving Touch Scale (PICTS; Koukounari et al., 2015), which were not included in the current study.

Implementation of Daily Log

In addition, this was the first infant massage study to implement a daily log.

Although Oswalt (2009) attempted to implement a daily worksheet for monitoring compliance of infant massage, none were completed or returned. As such, the researchers suggested that in future studies, participants be asked about massage frequency at follow- up interviews to assess compliance with massage intervention. For the current study, the

14-day daily log revealed some interesting correlations that could be further expanded on.

First, adolescent mothers who worked part time recorded massaging their infants more frequently than unemployed mothers. In addition, more surprisingly, adolescent mothers with a history of child welfare as a child reported massaging their infants more frequently. Lastly, the daily log revealed that adolescent mothers who massaged their infants more frequently scored lower on the PCAQ (i.e. less comfortable with touch).

Further examination of the demographic variables and outcome variables for maternal

attachment and touch could be expanded on in addition to assessing compliance and

implementation of FirstPlay® Therapy.

Qualitative Study

Lastly, following data collection, many of the adolescent mothers in this study verbally expressed their feelings to the researcher about learning the FirstPlay® Therapy, suggesting positive points about learning and utilizing a new, interactive model. One existing qualitative study has implemented infant massage with an adult mother population (Midstund et al., 2018). These researchers found that mothers reported their interactions with their infants were enhanced, the massage intervention allowed for more quality time with their infants, and their overall experience was positive. It may be beneficial, then, to add a qualitative component when replicating this study. This qualitative component could include a daily journal in which adolescent mothers could record their thoughts and feelings about and reactions to their infants immediately after

the massage.

Implications for Practice

Even though adolescent mothers can be a challenging population to engage and

retain in preventive programs, attachment intervention can support the adolescent

maternal–infant dyadic relationship (Crugnola et al., 2016; Mayers et al., 2008; Nicolson

et al., 2013; Oswalt et al., 2009). FirstPlay® Therapy was designed to be used with any

caregiver population, specifically targeting the parent–infant attachment relationship.

Although further studies are needed to expand on the current one, this study provides

insight into the feasibility of teaching infant massage-storytelling as a component of a group maternity home curriculum.

In this study, all group homes that participated in the study expressed an interest in making FirstPlay® Therapy part of their daily curriculum. Because FirstPlay®

Therapy can be easily incorporated as a practice model, staff could complete a 40-hour online or in-person training to become certified in FirstPlay® Therapy. Direct staff who become trained in FirstPlay® Therapy can work with adolescent mothers individually or in a group format. Although this study did not have enough participants from one home to incorporate a FirstPlay® Therapy group session, this would be a feasible option for future implementation of FirstPlay® Therapy.

FirstPlay® Therapy was designed to be implemented with any primary caretaker.

Recently, the group homes involved in this study have begun to include fathers as part of increased involvement with their infants and building positive relationships. The rationale for looking at fathers is supported by the writings of Bowlby (1982), who proposed that infants become attached to several different figures, usually represented by the adults with whom they have regular interaction. Although fathers do not live at the group homes, they are increasingly becoming included and involved in the day-to-day life of their infants. Future studies could focus on incorporating FirstPlay® Therapy not only with adolescent mothers, but also with adolescent fathers, to build healthy, infant attachment with both parents.

Conclusion

This pilot study examined the effect of an adjunctive play therapy model called

FirstPlay® Therapy on maternal attachment and comfort with physical touch among a

sample of five adolescent mothers and their infants. The study is the first known study to

examine these factors with an adolescent mother population in a group home setting. It

explored the effectiveness of teaching adolescent mothers how to utilize nurturing touch

with their infants to increase the maternal–infant attachment relationship. As the first-

known pilot implementation of FirstPlay® Therapy, findings serve as a point of

comparison with other attachment studies with an adolescent mother population.

Although this study did not produce any statistically significant findings, results

suggested that future research may discover that these caring, respectful, attuned, and

joyful activities between the adolescent mother and her infant could build trust and

security in the infant and increase maternal–infant attachment.

Practitioners who work with high-risk populations, such as adolescent mothers, can intervene to provide education and parent training in responsive and nurturing touch to prevent abuse and neglect. They can also provide a corrective experience for parents who may need guidance in providing touch appropriately. The findings of the study can be used to guide the implementation of future attachment intervention research addressing the maternal attachment relationship with an adolescent mother population. It is hoped that in addition to adding to the existing literature on adolescent mothers and attachment, it will provide a framework for future research to expand on this new play- therapy model.

Table 1

Baseline Participant Characteristics (N = 6)

n % Mean SD Range Age of mother 19.33 1.03 18-21 18 1 16.7 19 3 50.0 20 1 16.7 21 1 16.7 Age of infant in weeks 13.33 13.75 5-40 4–13 4 50.0 14–23 1 16.7 24–33 0______34–43 1 16.7 44–52 0______Infant’s gender Boy 3 50.0 Girl 3 50.0 Ethnicity African-American 3 50.0 Asian 0______Hispanic 2 33.3 Caucasian 0______Other 1 16.7 Highest level of education Middle school (6th-8th grade) 0______Some high school (9th-11th 2 33.3 grade) High school (12th grade) 2 33.3

n % Mean SD Range Completed GED 2 33.3 Technical school 0______Some college or technical school 0______Current status of employment Full time 0______Part time 2 33.3 Unemployed 4 66.7 Child-welfare involvement Yes 2 33.3 No 4 66.7 Massage length of time in minutes 7.16 3.68 3.2-11.1 Recorded days massage completed 10.0 3.91 5-14

Table 2

Correlational Table

1 2 3 4 5 6 7 1. Participant age, years ―

2. Age of infant, weeks .850* ―

3. Gender of infant .000 .372 ― 4. Mother’s race –.791 –.451 .447 ― 5. Mother’s education –.433 –.325 –.408 .274 ―

6. Participant employment –.875* –.826* .000 .632 .000 ―

7. Child-welfare history –.875* –.826* .000 .632 .000 1.00** ―

8. MAI pre-total –.320 –.343 .521 .368 –.235 .291 .291

9. MAI post-total –.148 –.391 .308 .129 –.605 .404 .404

10. PCAQ pre-total –.099 –.556 .051 .319 –.570 .439 .439

11. PCAQ post-total –.423 .057 .880* .863 –.029 .350 .350

12. Average time/day –.865 –.888 –.272 .404 .381 .962* .962*

13. # of days out of 14 .462 –.060 –.885 –.851 .000 –.442 –.442

*p < .05. **p < .01.

Table 2

Correlational Table (Continued)

8 9 10 11 12 13 8. MAI pre-total ― 9. MAI post-total .887* ― 10. PCAQ pre-total .074 .942 ― 11. PCAQ post-total .288 .019 .377 ― 12. Average time/day .284 .185 .251 .066 ― 13. # of days out of 14 –.371 .730 –.977 –.986* –.186 ―

*p < .05. **p < .01.

Table 3

Cross Tabulation: Age of Mother in Years;*Age of Infant in Weeks

Age of infant in weeks 5.00 9.00 16.00 40.00 Total Age of 18.00 Count 0 0 0 0 1 participant (mother) in % within 0.0 100.0 0.0 0.0 100.0 years age of participant (mother) in years 19.00 Count 3 0 0 0 3 % within 100.0 0.0 0.0 0.0 100.0 age of participant (mother) in years 20.00 Count 0 0 1 0 1 % within 0.0 0.0 100.0 0.0 100.0 age of participant (mother) in years 21.00 Count 0 0 0 1 1 % within 0.0 0.0 0.0 100.0 100.0 age of participant (mother) in years Total Count 3 1 1 1 6 % within 50.0 16.7 16.7 16.7 100.0 age of participant (mother) in years

Table 4

Cross tabulation: Mother’s Current Status of Employment; *Mother’s Child-Welfare History

Participant child-welfare history as child Yes No Total Participant Part time Count 2 0 2 current status % within 100 0.0 100 of participant employment current status of employment Unemployed Count 0 4 4 % within 0.0 100.0 100.0 participant current status of employment Total Count 2 4 6 % within 33.3 66.7 100.0 participant current status of employment

Table 5

Paired Sample Test for Maternal Attachment Inventory and Physical Contact Assessment Questionnaire ______Pretest Posttest n of 6 n of 5

Variable M (SD) M (SD) t p ______MAI 32.6 (6.80) 32.2 (9.49) .192 .857

PCAQ 41.5 (2.38) 40.25 (9.84) .271 .804 ______

Appendices

Appendix G

Parent Review Checklist

Check Parent Discussion List First and above all enjoy your time with your infant. Relax! As you relax—it helps your baby to relax. Develop a daily ritual of having a specific time and place for the FirstPlay® experience. (Best to find the times when your baby is in a “quiet alert” state) Wash hands thoroughly before you begin. Warm your hands prior to the massage ~ cold hands can be startling. Use a soft blanket for them to lie on. A large pillow might also be helpful for some positions. Before you begin a FirstPlay® session, always ask permission first from your baby to massage. You can do this by holding your hands together above your baby’s face so they can know it’s time for a massage. Joyfully tell your baby that it’s time for a massage. Tune into your baby’s verbal and physical responses. Play relaxing soft music—the same songs can be a cue to your baby that you are getting ready for your special time together If your baby is not in the mood for a massage, then try again later that day Avoid a FirstPlay® massage when the infant has a full stomach.

Always begin with the feet and legs—if that is as far as you get than that is plenty enough for the moment. Remember that only a few minutes of massage time can be enough. Remove jewelry before beginning ~necklaces that may dangle, or rings that can scrap.

Be mindful of the length of nails so as to not scratch the infant. Use an oil of your choosing including, cold-pressed Grape Seed oil, or Sunflower oil, or almond oil. Dab a little oil on your baby’s leg to first to test for any skin sensitivities before using the oil. *Best to have the parent ask their pediatrician for oil recommendations. Dry your hands of oil before you massage your baby’s face. Remember that some babies do not like to have their face massaged—know that they might change over time. Be mindful of the room temperature—keep it warm enough for your baby to be comfortable. Avoid overhead lighting. Most of all—play—sing—give kisses—blow kisses—have fun—enjoy!

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