Infant and Child Development Inf Child Dev 10: 93–115...

Infant and Child DevelopmentInf. Child Dev. 10: 93–115 (2001)DOI: 10.1002/icd.236

Early Tactile Experience of LowBirth Weight Children: Links toLater Mental Health and SocialAdaptation

Sandra J. Weissa,*, Peggy Wilsonb , Mary St. Jonn Seedc

and Steven M. Pauld

a Department of Community Health Systems, School of Nursing,University of California, San Francisco, CA, USAb San Francisco General Hospital, San Francisco, CA, USAc School of Nursing, University of San Francisco, San Francisco, CA, USAd School of Nursing, University of California, San Francisco, CA, USA

The purpose of this study was twofold: to determine (1) thedegree to which specific qualities of maternal touch may con-tribute to the low birth weight infant’s emotional and be-havioural problems as well as social adaptation, and (2) therelationship between maternal touch and a mother’s othercaregiving behaviour. The sample included 114 socioculturallydiverse infants and their mothers who were videotaped duringan infant feeding when the baby was 3 months old. Thisvideotape was analysed to assess dimensions of mother–infantinteraction, including maternal touch. Data on perinatal risk andthe mother’s acceptance versus rejection of the infant were alsoacquired. Social adaptation and emotional/behavioural problemswere measured when the child was 2 years of age.

Hierarchical regression analyses indicated that maternal touchaccounted for 15% of the variance in the likelihood of a childhaving emotional/behavioural problems at age 2. Children whoreceived more nurturing touch had significantly fewer internal-izing problems (such as depression) while children receivingboth more frequent touch and harsh touch had more externaliz-ing problems (such as aggressive behaviour). Infants who wereless responsive to their caregivers were especially at risk ofdeveloping aggressive/destructive behaviour as a result of fre-quent touch. But less responsive infants also appeared to benefitmost from greater use of diverse types of maternal touch, ac-counting for 6% of the variance in superior adaptive behaviourat age 2. Nurturing touch was the only quality that showed evena modest relationship to other caregiving behaviour, suggesting

* Correspondence to: Department of Community Health Systems, Box 0608, School of Nursing,University of California, San Francisco, CA 94143, USA. E-mail: [email protected]

Copyright © 2001 John Wiley & Sons, Ltd.

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that touch may play a distinct role in the infant’s psychosocialdevelopment. Copyright © 2001 John Wiley & Sons, Ltd.

Key words: adaptive behaviour; behaviour problems; high risk; lowbirth weight; parenting; touch

The growing evidence of social and emotional problems for low birth weightchildren cannot be dismissed. Studies suggest that emotional immaturity, poorsocial competence and both internalizing and externalizing psychiatric disordershamper low birth weight children (Breslau et al., 1988). Early behaviour prob-lems, in turn, predict their later social and emotional functioning (Velez et al.,1989), especially conduct disorders and delinquency (Brooks-Gunn and Bena-sich, 1997). The prevalence of moderate to severe behaviour problems rangesfrom 10 to 16% for low birth weight infants (McCormick et al., 1990), increasingto 15–25% for babies less than 1500 g (Hay et al., 1992; Bennett, 1997).

Various characteristics of the infant have been found to affect the likelihood ofproblems developing, such as smaller birth weight, more perinatal complica-tions and male gender (Bennett, 1988; Breslau et al., 1988; Pharaoh et al., 1994;Brooks-Gunn et al., 1997). But these characteristics interact dynamically with theenvironment from the first days of the baby’s life. During the first few months,the basic structure and functions of the brain are shaped (Sylva, 1997), particu-larly by sensory experience from social interaction (Harris, 1998). It is theresulting patterns of neuronal connectivity and neurochemical organization thatcreate internal representations which will guide an infant’s future emotional andbehavioural potential (Thoenen, 1995; Shore, 1997).

THE TACTILE ENVIRONMENT AS A FOUNDATION FORPSYCHOSOCIAL DEVELOPMENT

Many features of the infant’s environment help to shape neurobehaviouraldevelopment; however, tactile experience may play an early and significant role.Receptors and neural pathways associated with touch are the first to develop ininfancy and the baby’s primary stimulation is through the touch received in care(Turkewitz and Kenny, 1982; Myslivecek, 1991). As a result, touch is central todevelopment of the brain’s ‘hardwiring’ during this initial period. Evidencefrom animal models indicates that the nature of early tactile experience canindeed affect the size of the brain’s cortex as well as the numbers and patternsof connections between nerve cells in the brain (Greenough, 1990; Nudo et al.,1996). To a great extent, the brain of the newborn develops through sensory andmotor stimulation acquired from body contact with the mother (Larsson, 1994).

However, because of their fragile or underdeveloped nervous systems, lowbirth weight infants have a diminished ability to regulate their responses totactile stimulation during the first few months of life (Als et al., 1986; Gunnar etal., 1987; Harrison et al., 1990). They may also be especially vulnerable to touchbecause of their history of invasive and painful medical procedures which candistort their somatosensory perception and increase the potential for touch to beaversive (DeMaio-Feldman, 1994). But, despite the unique challenges faced bythese infants in regard to touch, nothing is known of the longer term conse-quences of parental touch patterns for the eventual mental health or socialadaptation of low birth weight infants. A goal of this study was to better

Copyright © 2001 John Wiley & Sons, Ltd. Inf. Child Dev. 10: 93–115 (2001)

Early Tactile Experience 95

understand the effects of various qualities of touch on these infants by buildingupon what is known about touch from research using other human and animalmodels.

Frequency of Touch

Research using animal models has identified numerous dysfunctions resultingfrom the absence or infrequency of physical contact during infancy, includingrepetitive, stereotyped rocking or head banging, unusual posturing, self-clingingand self-touching, withdrawal and fear of exploration, depressive affect, anxiousbehaviour, and failure to participate in normal social relationships such as mutualgrooming (Harlow, 1958; Suomi, 1986, 1990).

These studies parallel the findings of human research which show that rejectionof physical contact by attachment figures can lead to angry, aggressive behaviourby the child as well as abnormal stereotypies such as hair pulling and handflapping (Main and Stattman, 1981). Blunted affect has also been noted as a keyfeature in physically neglected infants (Schore, 1998) as well as infants diagnosedwith ‘failure-to-thrive’ (Spitz, 1945). Studies of children with ‘failure-to-thrive’describe patterns of less overall touch from their mothers (especially holding,kissing and caressing) as well as evidence of mothers obstructing the child’sphysical access to them and verbal reprimands to the child not to touch them(Pollitt et al., 1975; Polan and Ward, 1994). The discovery of a gene that is triggeredby touch (Schanberg, 1995) may ultimately help to explain these findingsregarding failure to thrive. In addition, data from a recent randomized trialindicate that human neonates cry immediately when not in skin-to-skin contactwith the mother (Christensson et al., 1995). The investigators conducting thatresearch suggest that the ‘distress call’ of neonates may be a genetically encodedreaction to separation which attests to the infant’s biological need for closephysical contact with the mother.

Beyond these studies of touch deprivation, animal research has providedevidence that greater tactile stimulation in early life may ‘program’ a moreeffective regulation of the stress response in later life. Rats whose mothers lickand groom them more frequently as pups show reduced hormonal reactivity toacute stress, increased receptor mechanisms for the detection and uptake of stresshormones, and faster recovery from stressors when they become adults (Liu etal., 1997; Francis et al., 1999). In contrast to other rats, those who receive morelicking and grooming as pups also exhibit behaviour indicating less anxiety laterin life (e.g. more open field exploration) and more brain receptors for the uptakeof chemicals that reduce anxiety (Sapolsky, 1997). These findings suggest animportant link between early tactile experience and one’s subsequent emotionalresponse to the stress encountered in life.

Complexity/Diversity of Touch

A predominant feature of tactile deprivation is the lack of enrichment that sucha condition provides to the developing child. Animal models have profferedgrowing support for the hypothesis that more complex, varied or diverse tactileenvironments enhance brain development, producing (a) greater numbers ofneuronal connections for animals reared in enriched environments (Greenoughet al., 1985) and (b) increased numbers of genes and neurons responsible forlearning and memory function (Anokhin et al., 1991; Kempermann et al., 1997).Tactile enrichment, in contrast to deprivation, has apparent implications forimproving the cognitive, emotional and behavioural repertoires available to thechild for dealing with the challenges of life.


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Nurturing Touch

Research constructs a picture of the special importance of caressing and com-forting skin contact between parent and child in fostering a sense of beingvalued that influences profoundly the child’s emotional and social development(Walsh, 1991). Tender, gentle holding and touching have been identified ascentral to a child’s secure attachment and emotional security (Ainsworth et al.,1978; Anisfeld et al., 1990; Kaitz et al., 1992), serving as the primary meansthrough which support and tenderness are communicated prelinguistically. Inparticular, caressing and close holding seem to indicate special nurturance andintimacy (Kaitz et al., 1995). In addition to the emotional security fostered bynurturing touch, it has been proposed that an infant’s later ability to feel andexpress empathy and caring toward others depends, to a great extent, on thatinfant’s earliest tactile experience and whether s/he was touched in a caring way(Ziajka, 1981; Perry et al., 1995).

Primate studies provide evidence that nurturant physical caregiving by mon-key mothers can be the crucial factor in infant development of emotionalsecurity and social competence, especially in more temperamentally vulnerableinfants (Suomi, 1990, 1997). When these infants do not have nurturant mothers,they develop numerous behavioural problems, and lack the skills to succeed orbe accepted in the primate social world.

Harsh Touch

There is a growing literature indicating high rates of mental health morbidityfor children experiencing early physical abuse (Kolko, 1992) and physicalpunishment (Straus and Gelles, 1990). Even as infants, these children begin toshow substantial negative affect and minimal positive affect (Schore, 1998),becoming physically aggressive to their peers and caregivers as they develop(Main and George, 1985). Ultimately, physical maltreatment increases the child’srisk for full blown neuropsychiatric syndromes, especially depression, aggres-sive and destructive behaviour, and self-destructive disorders (Kaufman, 1991;Green, 1998). Although it is difficult to separate out the specific effects of strictlyphysical abuse versus its concomitant emotional abuse, research suggests thatpunitive forms of touch may actually alter the neural structure and neurochem-ical circuits of the corticolimbic system, the system responsible for processingsocioemotional experience (Perry and Pollard, 1998; Schore, 1998).

Touch: Autonomous Entity or Caregiving Marker?

In nearly all of the research cited above, it is difficult to separate out the discreteeffects of touch from overarching attitudes or styles present in the caregivingenvironment which may be affecting the infant’s development. Touch mayreflect a marker of the larger caregiving approach, just as variables such asamount of maternal vocalization, eye contact or smiling may serve as indicatorsof the caregiver’s attentiveness, warmth or sensitivity toward the child. Forinstance, greater use of tender, affectionate touch has been long considered anattribute of maternal sensitivity (Ainsworth et al., 1978).

Yet, there are important distinctions in the various facets of caregivingbehaviour. While many aspects of maternal behaviour may be associated withmore optimal outcomes, these behaviours are not necessarily interdependentnor redundant. Seifer and Schiller (1995) have provided evidence of such adistinction between maternal warmth and sensitivity; a mother may have one



attribute without possessing the other. Similarly, caregivers can show overallwarmth and concern while using qualities of touch that may have potentiallyaversive or negative effects on the child (Harrison et al., 1990; Weiss, 1993).Research has also shown that people can communicate different content simul-taneously through different sensory modalities (Ekman et al., 1988; Sanders andDadds, 1992; Mestel, 1996). An obvious example is someone smiling while usingcritical or hostile words. Montague (1986) has noted that, in public situations,people often use touch in ways that either (a) contradict their words or facialexpression, or (b) communicate something unrelated to other sensory channels.For instance, a mother may use harsh touch to restrain and control her ebullientchild while concealing her irritation from others via a pleasant voice andpositive facial affect. Such observations raise important questions about therelationship of touch to the more general caregiving behaviour of the mother.Yet there is little knowledge to date regarding how these systems function inrelation to one another.

RESEARCH AIMS

There were two major aims of this study. The first was to determine thecontribution of frequent, diverse, nurturing and harsh properties of maternaltouch to the psychosocial development of low birth weight infants at 2 years ofage. We hypothesized that these properties would contribute significantly to thevariance in emotional and behavioural problems for infants as well as to theirsocial adaptation. However, we predicted that their effects would depend, tosome extent, upon their interaction with the particular biological makeup andinteractive capacity of the infant. Perinatal risk status, birth weight and genderwere selected as salient biological variables which could moderate the effects ofmaternal touch. Infant responsiveness and clarity of cues were included as twoadditional moderating variables.

The second research aim was to examine the relationship between propertiesof maternal touch and the overarching nature of the mother’s caregivingbehaviour with the low birth weight child. We hypothesized that greater use ofnurturing touch would be positively related to more general maternal warmth,responsiveness to the child’s distress, and more socioemotional growth fosteringbehaviour. In contrast, a mother’s use of harsh touch would be related to morerejection of the infant, less responsiveness to distress and less socioemotionalgrowth fostering. We also hypothesized that greater diversity in maternal touchwould be related positively to more cognitive growth-fostering behaviour by themother and greater sensitivity to the infant’s cues. Lastly, we predicted thatfrequency of touch would have no relationship to a mother’s caregiving be-haviour because the qualitative characteristics of touch, rather than its simpleamount, would be more likely to reflect the mother’s overarching caregivingapproach.

METHODS

Sample

The sample included 114 infants and their mothers who were recruited into thestudy during the infant’s first 2 weeks of life and followed through their second


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birthday. This convenience sample was ethnically diverse, including 46% Cau-casian, 28% Hispanic, 19% African–American, and 7% Asian or Native Ameri-can babies. Their weight ranged from 570 to 2500 g with a mean birth weight of1487 g (S.D.=547). Ninety-four percent of the babies had a gestational age ofless than 37 weeks, with a sample mean of 32 weeks. Forty-four percent of thebabies were girls and 56% were boys, with 22% known to have been drugexposed in utero. Mothers had a mean age of 29 years (S.D.=7), ranging from16 to 44. They averaged 12.5 years of education (S.D.=4), with a spread from 1to 20 years. Eighty-one percent of the mothers lived with their partner, but notnecessarily a spouse. Forty-five percent of the mothers were living below thepoverty level. Sixty-one percent were employed at least part time, with 29%being the sole support for their family.

Procedures

Families were recruited from the neonatal intensive care units of three majorteaching hospitals. Once an informed consent was acquired, the mother wasgiven a demographic questionnaire regarding both herself and her baby tocomplete. When the baby was 1 month old, a research assistant (RA) withclinical expertise in care of neonates reviewed the medical charts of mother andinfant to identify the presence or absence of specific perinatal risk factors thatconstituted the Parmelee Perinatal Complications Scale. When the baby was 3months of age, a RA who was a clinical nurse specialist made a home visit tovideotape the mother and infant during a typical feeding. Mothers fed the infantin their normal feeding mode, either breast (31%) or bottle (69%). The videocamera was set up and turned on as soon as the RA arrived in order to allowtime for the mother to adjust to its presence. The camera was then left focusedon the mother and infant while the baby was being fed. The videotape of thefeeding was analysed at a later time using the Tactile Interaction Index (tomeasure the mother’s use of touch) and the NCAST feeding scales (to measurethe infant’s interactive capacity and the mother’s caregiving style). Mothers alsocompleted the Parental Acceptance–Rejection Questionnaire at the 3-month visitto measure their warmth versus rejection of the infant. Near the infant’s secondbirthday (corrected for gestational age), an appointment was set to interview themother regarding her child’s social adaptation, using the Vineland AdaptiveBehaviour Scales. She was also asked to complete Achenbach’s Child BehaviourChecklist/2-3 at this time, describing any emotional or behavioural problems sheobserved for her child. Because this study represented only one aspect of alarger programme of research, RAs were in quarterly contact through telephonecalls or visits with the families between the 3-month and 2-year home visits.

Measures

Perinatal Risk StatusRisk status was determined by the Perinatal Complications Scale, developed

by Parmelee (Parmelee et al., 1976; Littman and Parmelee, 1978). The measureassesses maternal obstetrical history, pregnancy events, perinatal measures ofthe infant (e.g. gestational age and apgar), and hazardous postnatal events suchas need for ventilatory assistance, metabolic abnormality, or surgery. A sum-mary score is based on the number of risk factors incurred by a mother– infantpair, with higher scores indicating greater risk. Risk data were acquired pri-marily from chart review during the first month postnatal, with supplementalinput from the infant’s primary nurse. Reliability and validity have been



demonstrated for the scale (Francis et al., 1987; Scott et al., 1997). Although it wasdeveloped in the 1970s, the scale’s categories are still highly salient and broadenough for classification of the most contemporary of medical complications.Infant–Mother Interaction

The NCAST Feeding Scale (Barnard et al., 1989) was used to measure thenature of the videotaped maternal–child interaction: both an infant’s interactivecapacity with the mother and the mother’s caregiving behaviour toward thechild. We coded the two infant subscales (clarity of cues and responsiveness tothe mother) and the four maternal subscales (sensitivity to cues, responsivenessto distress, socioemotional growth fostering, and cognitive growth fostering).The NCAST measure has established normative data and has shown internalconsistency and test-retest reliability as well as construct, concurrent and predic-tive validity (Sumner and Spietz, 1994). The subscales each consist of binaryitems which are summed; larger scores indicate more of the particular be-haviour in question.

An expert coder was trained and certified as reliable in use of the NCASTScales by the University of Washington NCAST office (i.e. met their criterion ofat least 85% reliability on a series of standardized observational tests). Thisindividual completed the coding for all infants based upon review of the entirevideotape of their feeding situation with the mother. The coder was blind to anyother information about the mother– infant pairs.Maternal Acceptance–Rejection

A mother’s acceptance versus rejection of her infant was measured using theParental Acceptance–Rejection Questionnaire (Rohner, 1991). This measure is aself-report tool regarding the mother’s specific behaviour toward the infant.Sixty items provide a total composite score for degree of acceptance versusrejection on bipolar ends of a continuum where more overall rejection yields ahigher score. There are four subscales contributing to the total rejection score:lack of warmth/affection, aggression/hostility, neglect/indifference and undiffer-entiated rejection. A subscale score for overall warmth can also be determined.Each item is on a four point scale from almost never true to almost always true.

The reliability of the measure has been demonstrated (Rohner, 1991; McGuireand Earls, 1993), with the internal consistency of the total scale having an alphaof 0.91. Subscales range from 0.86–0.95. Content, concurrent, convergent anddiscriminant validity have also been established (Holden and Edwards, 1989;Rohner, 1991; Myers et al., 1992; Gorman et al., 1993). Response bias and socialdesirability have been tested with no evidence of their effects. The measureshows substantial cross-cultural validity and utility.Maternal Touch

The specific properties used by mothers in their touching of infants weremeasured with the Tactile Interaction Index (Weiss, 1990, 1992). The Index (TII)includes both a series of training videotapes differentiating various properties oftouch as well as a coding system to analyse these properties within a specifiedinteraction. The coding system has indices measuring the intensity, location,action and frequency of a touch. It was created specifically for microanalysis ofvideotaped or filmed interaction.

The intensity index allows for coding of touch as strong, moderate or lightbased on the degree of pressure to the skin. Each mother received an initial rawscore for the number of times she used each type of intensity in her touchingand then a percentage score for the degree to which she used each of the threeintensities during the feeding situation.


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The location index specifies 19 different areas of the infant’s body that couldbe touched. Each touch that occurs is coded as to which body area the mothertouches. From initial raw scores regarding the number of times each area wastouched, a percentage score was developed, to identify the extent to which avariety of different body areas were touched, that is, the percentage of differentareas a mother touched from among the 19 possible.

The action index identifies 28 different gestures or movements that can beused in touching (e.g. grab, push, rub, squeeze). From the raw data regardingspecific tactile gestures, three percentage scores were developed. The first scorerated each mother on the degree to which she used nurturing actions (e.g.stroking, kissing) and the second score identified the degree of harsh actions(e.g. pinching, slapping). A third score was computed regarding the variety ofactions used (i.e. the number of different actions from among the 28 possible).

The fourth index identified the frequency of a mother’s touching, being theactual number of times a mother touched her baby. This was the only score thatwas not a percentage score.

From these TII data, four final scores were used to test the hypotheses of thisstudy: (1) nurturing touch, (2) harsh touch, (3) frequent touch, and (4) complex/diverse touch. The first three scores came directly from the original index scoresjust described. Diversity (complexity) of touch was operationally defined bysumming scores for (a) the extent of body areas touched and (b) the variety ofactions used in touching.

The content, construct and predictive validity, as well as internal consistency,interrater reliability and test–retest stability of the TII have been establishedpreviously (Weiss, 1990, 1992). Data from the sample of mothers in the studyreported here have provided further evidence of the measure’s validity andreliability.

A standardized 5-min segment of the infant feeding situation was used foranalysis of each mother’s touch. The initial few minutes of the feeding were notused in order to allow mothers to adjust comfortably to their normal feedingroutine. Two subsequent minutes were then coded during active feeding of thebaby. Three additional minutes near the end of the feeding were also coded,when mothers were concluding the feeding, burping the baby, and engaging inother interaction with the infant unrelated to the feeding per se. While standard-izing the times of the feeding limited some of the variance in overall frequencyof touch, it was necessary in light of a number of factors, including the lengthof some feeds, periods where the baby was sleeping with no interaction takingplace, and the time-intensive nature of the tactile coding process. Yet thenatural, spontaneous quality of the feeding was preserved by standardizingwhat was coded rather than rigidly structuring the feeding situation itself.

A trained RA who analyzed the touch reviewed the 5-min feeding tapes fourseparate times, coding each of the original indices separately (i.e. intensity,action, location and frequency of touch). She was reliable at the 0.92 level orabove for each index with another expert coder. This RA had no other contactwith the families participating in the study, nor any access to information aboutthem.

Adaptive Social BehaviourThe Vineland Adaptive Behaviour Scales were employed as a measure of

adaptive social behaviour (Sparrow et al., 1984). The items in the measure areeach on a three-point scale and are divided into three separate domains:communication, daily living skills, and socialization. There is also a motor skills



domain which was not used in this study. We used the combined adaptivebehaviour composite of the three social adaptation subscales as the majordependent variable in this research. A child’s placement on the items was basedupon interview with the mother when her child was 2 years of age. Split-half,test–retest and interrater reliability have been established for the measure aswell as concurrent and predictive validity (Poth and Barnett, 1988; Middleton etal., 1990; Raggio and Massingale, 1990; Atkinson et al., 1992).

Because we were dependent upon maternal report of the infant’s adaptivebehaviour, we looked for evidence within our own database to support thevalidity of the Vineland scores. Cognitive ability has been clearly linked to socialadaptation in previous research (e.g. Liaw and Brooks-Gunn, 1994; Harris, 1998)so we compared the infants’ adaptation scores with scores from a measure ofthe infant’s cognitive ability (the Mullen Scales of Early Learning) which we hadacquired as part of a separate study in the larger research programme. Thesecognitive tests were administered by a developmental psychologist when theinfant was 2 years of age. The correlation between the Vineland composite scorefor social adaptation and the sum score for the infant’s cognitive status wasr=0.61 (p�0.000). The most directly linked variables within the Vineland andthe Mullen Scales are the measure of ‘language expression’ in the Mullen andthe subscale for ‘communication skills’ in the Vineland. This correlation wasr=0.68 (p�0.000), providing support for the validity of the mother’s reportabout her infant’s adaptive behaviour.

Emotional and Behavioural ProblemsThe Child Behaviour Checklist (CBC) for 2–3 year olds was used to assess the

degree of behavioural and emotional problems manifested by children at 2 yearsof age (Achenbach, 1992). This questionnaire consists of 99 items describingpotential problems that a child might experience, each on a three-point scale.The checklist provides a total problem score, scores for externalizing andinternalizing problem behaviours and six scales indicating specific syndromes,each with standardized comparison scores for a normative sample. Syndromescores include social withdrawal, anxiety/depression, sleep disorders, somaticproblems, aggression, and destructive behaviour. The total score as well asscores for externalizing and internalizing disorders were used as the primaryindices to determine emotional and behavioural problems because the reliabilityof these scores is the most robust and least subject to measurement error.Syndrome scores were examined only to understand some specific features ofthe overall results.

Because of the early age of our infants, we were dependent upon maternalreport as the basis of a child’s problem assessment. However, for a smallsubsample of our families in whom fathers were also willing to complete theCBC for their infant (n=20), we found a reliability of r=0.71 (p�0.0l) betweenour mothers’ and fathers’ total problem scores. This level of agreement isactually better than the average parental agreement for 2-year olds noted byAchenbach (1992) of r=0.63.

The questionnaire has been tested and normed with a broad cross section ofSES and cultural groups as well as children with varying degrees of perinatalrisk. Its reliability and validity have been documented in numerous studies(Crawford and Lee, 1991; Achenbach, 1992; Spiker et al., 1992; Leadbeater andBishop, 1994), including internal consistency, stability, and discriminant andpredictive validity. In order to feel more confident about the validity of ourmothers’ descriptions of their children’s emotional and behavioural problems,



we correlated the infants’ total problem scores on the CBC with their scores forsecurity of attachment from another study within our larger programme ofresearch. Security of attachment has been linked to fewer behavioural problemsin children (e.g. Carlson and Sroufe, 1995; Greenberg, 1999). Our data indicate asignificant negative correlation between the degree of attachment security forour sample of infants (measured in the home by trained observers using Watersand Deane’s Attachment Q-Set) and the infants’ total number of emotional andbehavioural problems (r= −0.23, p�0.02). This evidence of construct validityaugmented our confidence in the mother’s evaluation of her child’s emotionaland behavioural problems.

Data Analysis

Data analysis for Aim c1 involved two phases. First, separate multiple regres-sions were performed for each of the touch variables to determine theirindividual contributions to adaptive social behaviour and to emotional/behavioural problems. This phase allowed for determination of their maineffects as well as any potential impact of their interactions with infant character-istics. Total scores for adaptive behaviour and for behavioural problems servedas the two dependent variables. Separate hierarchical regression equations werecomputed for each touch variable with each dependent variable. At the firststep, three variables reflecting the infant’s biological makeup were entered(gender, birth weight, perinatal risk status). At the second step, two variablesindicative of infant interactive capacity were entered (clarity of cues andresponsiveness). At the third step, the score for one of the touch variables wasentered. Five interaction terms were entered at the fourth step, representing theinteractions of all variables in steps 1 and 2 with the particular touch variableentered in Step 3. All touch variables and interaction terms that were significantat p�0.05 or better were then reserved for further examination in the secondphase of data analysis.

In the second phase, hierarchical multiple regression procedures were againemployed, with separate equations for each of the outcome variables and entryof the same moderating variables at steps 1 and 2 to control for their effects.However, in this phase, any touch variable and any interactions which hadshown a significant relationship to the particular outcome variable in phase 1were all entered, respectively, at steps 3 and 4.

Only nine of the mothers used any harsh touch so there was not adequatepower to perform regressions for that touch variable. However, two otherprocedures were used to determine whether a potential relationship existedbetween harsh touch and the outcome variables. First, Pearson correlations werecomputed to examine the degree of the relationship between harsh touch andthe outcome variables. Secondly, t-tests were employed to compare both theadaptive behaviour and problem scores of infants whose mothers used anyharsh touch (n=9) with those infants whose mothers used a substantial amountof nurturing touch, that is, at least 75% of their total touching (n=12).

To test Aim c2, Pearson correlation coefficients were computed to examinethe relationships between properties of maternal touch and the six characteris-tics of a mother’s more general caregiving (sensitivity to cues, responsiveness todistress, socioemotional and cognitive growth fostering, warmth and rejection).Because of the small number of mothers using harsh touch, for this variable, weused t-tests to compare the caregiving behaviour of mothers who used anyharsh touch with the group of mothers who used substantial amounts ofnurturing touch.



RESULTS

Maternal Touch Descriptors

Within the standardized feeding period, mothers touched their babies anaverage of 213 times (S.D.=109), ranging from 41 to 714 touches. Most maternaltouching was of the infant’s trunk (M=72%, S.D.=0.16), especially the back.Patting was the most common of the 26 gestures used. The particular propertiesof touch they used varied substantially across mothers. However, as an average,approximately half of a mother’s touch was nurturing (47%), with a range from0 to 91%. Complex/diverse touch constituted an average of 32% across mothers,with a range from 27 to 66%. For the nine mothers who used any harsh touch,their mean for its use was 2% of their total touch, with a range from 1 to 19%.

Maternal age, income and years of education had no relationship to thefrequency or diversity of maternal touch. However, a mother’s use of nurturingtouch was positively associated with more adequate financial income (r=0.19,p�0.04), older age (r=0.25, p�0.004) and years of education (r=0.34, p�0.000). Once we controlled for these socioeconomic variables, we found nodifferences across ethnic groups in their patterns of touch. Although the differ-ence in adjusted means was not significant, it is interesting to note thatAfrican–American mothers touched their infants the most frequently (M=226times). Hispanic mothers were in the middle of the spectrum with a mean of 207and Caucasian mothers touched the least frequently (M=199). Other ethnicitieswere not included in this analysis because of their small subsample size.

The Contribution of Touch to Psychosocial Development

Tables 1 and 2 present the regression results for the first aim. These tables reflectthe empirical models generated through the two-phase process of analysisdescribed earlier.

Adaptive Social BehaviourAs shown in step 1 of Table 1, the infant’s biological characteristics accounted

for 33% of the variance in adaptive behaviour. If we look at the squared

Table 1. Summary of hierarchical regression analysis for variables predicting adaptivesocial behaviour (N=81)

Variables Beta at final Squared semi-partial R2 changestep at step entered

Step 1 0.33*0.19*Gender −0.50*

−0.03 0.00Birth weight0.09*Risk −0.35*

0.04Step 20.06Clarity of cues 0.00

0.02Responsiveness 1.09*

Step 3 0.00Diversity of touch 1.09* 0.00

Step 4 0.06*Responsiveness×Diversity of touch −1.36* 0.06*

Total model: R2=0.43, F7, 73=7.97, p�0.0001.* p�0.01.



Table 2. Summary of hierarchical regression analysis for variables predicting emotionaland behavioural problems (N=75)

Beta at finalVariables Squared semi-partial R2 changeat step enteredstep

Step 1 0.060.05*Gender 0.24*0.010.23Birth weight

−0.02Risk 0.00

0.00Step 20.00−0.07Clarity of cues

0.63Responsiveness 0.00

Step 3 0.09*0.05*−0.24*Nurturing touch0.04Frequent touch 1.75*

Step 4 0.06*Responsiveness×Frequency −1.79* 0.06*

Total model: R2=0.21, F8, 68=2.20, p�0.04.* p�0.05.

semi-partial coefficient for gender (i.e. the correlation between gender and socialadaptation when all other predictors have been partialed out), we can see thatit had the greatest unique effect, with girls being more adaptive than boys.Perinatal risk also contributed significantly, with less risk predicting bettersocial adaptation. As noted in steps 2 and 3, infant interactive capacity at 3months of age and maternal touch for infants as a whole made no significantcontributions to social adaptation. However, the interaction between infantresponsiveness and a mother’s diverse touch (step 4) did account for a signifi-cant proportion of the variance in the infant’s adaptive behaviour. In otherwords, the effect of touch depended on the infant’s level of responsiveness.Diverse touching was linked to better adaptive outcomes for less responsiveinfants, but it appeared to have no effect on more responsive infants. Examina-tion of the correlation matrices for infants who were less responsive (i.e. belowthe sample mean for responsiveness) showed that the most significant correla-tion with diverse touch was for the adaptive subdomain of ‘daily living skills’(r=0.47, p�0.007). This score reflects a child’s personal living habits and taskperformance; for example, the ability to feed oneself with a spoon withoutspilling, use the toilet or potty-chair, and put away possessions when asked. Thetotal model accounted for 43% of the variance in a child’s adaptive behaviour(F7, 73=7.97, p�0.0001).

Emotional/Behavioural ProblemsIn contrast to their substantial effect on adaptive social behaviour, step 1 of

Table 2 indicates that an infant’s biological characteristics accounted for only 6%of the variance in his/her later development of emotional and behaviouralproblems. This effect was due primarily to gender differences, with boys havingsignificantly more problems than girls. The infant’s interactive capacity (step 2)accounted for none of the variance. But, at step 3, maternal touch accounted for9% of the variance, with nurturing touch and frequent touch both making acontribution. Infants whose mothers used more nurturing touch were reportedto have fewer problems, especially fewer internalizing problems such as depres-sion and anxiety. However, frequent touch showed a positive relationship to



development of emotional and behavioural problems. In addition to its maineffect for the entire sample, its interaction with infant responsiveness (step 4)contributed another 6% to the model. The relationship between frequenttouch and emotional/behavioural problems depended to a significant extenton the level of an infant’s responsiveness. Correlation matrices indicated thatfrequent touch was linked most significantly to externalizing disorders suchas aggression and destructive behaviour, especially for infants who were be-low the mean for responsiveness. The total model contributed to 21% of thevariance in a child’s emotional/behavioural problems (F6, 86=2.20, p�0.04).

Harsh Touch and Psychosocial OutcomesCorrelation coefficients for the small sample of mothers (n=9) who used

harsh touch did show a relationship between the degree to which theyslapped, pinched or hit the child and their child’s psychosocial development.The greater a mother’s use of harsh touch during the feeding, the moreemotional/behavioural problems were reported for her child (r=0.66, p�0.05), especially internalizing problems of depression, anxiety and withdrawal(r=0.72, p�0.03). t-Tests comparing children whose mothers used harshtouch with a group of children whose mothers were high in use of nurturingtouch (n=12) did not show any significant differences, although childrenreceiving harsh touch had a higher mean for their problem scores (M=40.3)than children receiving nurturing touch (M=33.5).

Correlations of harsh touch with a child’s total score for adaptive socialbehaviour showed a trend toward a negative relationship, specifically for‘daily living skills’ (r= −0.58, p�0.09). The more mothers used harsh touch,the lower was their child’s score for adaptive social behaviour. Comparisonof infants receiving harsh versus nurturing touch indicated that children re-ceiving harsh touch were less adaptive (M=269) than were children receiv-ing high degrees of nurturing touch (M=286). But, like the correlationcoefficient, this difference was only a trend (t=1.99, p�0.07).

Caregiving Behaviour and Maternal Touch

Results of the correlation matrix related to the second aim are shown inTable 3. For the full sample of infants, there were no significant relationshipsbetween any measure of caregiving behaviour and the properties of frequent,diverse or nurturing touch, not even a trend. Because our regression modelspointed to significant interaction effects between infant responsiveness andmaternal touch, we also computed correlations between touch and caregivingbehaviour separately for the less responsive and more responsive infants. Forthe group of more responsive infants, nurturing touch was associated signifi-cantly with a mother’s warmth toward the infant (r=0.25, p�0.02). How-ever, these variables were unrelated for less responsive infants. Results of thet-test comparing mothers who used harsh touch (n=9) with those using highamounts of nurturing touch (n=12) identified one trend toward a differencein caregiving behaviour between these groups. But it did not support ourhypothesis. Mothers who used some harsh touch during the feeding actuallyhad slightly higher scores for their socioemotional growth fostering behaviourwith the infant (M=12.50) than did the mothers who used high amounts ofnurturing touch (M=11.42), t=1.94 (df=18), p�0.06. While these twogroups were independent samples (i.e. none of the mothers using harsh touchalso used nurturing touch more than 75% of their total touch), we found that



Table 3. Pearson correlations for the relationship between qualities of maternal touchand maternal caregiving behaviour (N=114)

NurturingCaregiving behaviour Frequency of Diversity oftouch touch touch

0.01 0.05Sensitivity 0.13Responsiveness −0.03 0.07 0.02Socioemotional growth-fostering 0.12 0.08 0.06Cognitive growth-fostering −0.04−0.010.03

0.02Warmth 0.12 0.02Rejection 0.04 0.00−0.03

No coefficients are significant at p�0.05.

there was a positive correlation between a mother’s use of harsh touch andher use of nurturing touch (r=0.61). Because of the small sample size, thiscoefficient did not reach a level of significance; however, it indicated thatmothers who used harsh touch were also using nurturing touch with theirinfants.

This finding led us to question whether a mother’s lack of any nurturingtouch could be more of a marker for her overall warmth versus rejection orher socioemotional behaviour than the use of harsh touch per se. Indeed, thisanalysis showed that mothers who used absolutely no nurturing touch duringthe feeding (n=18) had significantly lower scores for socioemotional growthfostering (M=10.7) than mothers who used at least some nurturing touch(M=11.9), t=2.73 (df=26), p�0.01. In addition, the mothers who usedsome nurturing touch (n=96) were higher in their scores for warmth towardthe infant (M=65.2) than mothers who used no nurturing touch at all (M=62.9), t=2.43 (df=112), p�0.01. No other differences between these groupswere found in their caregiving behaviour.

DISCUSSION

The results of this study do indicate a potential link between the maternaltouch received by low birth weight infants during their early months of lifeand their later psychosocial development. Our findings suggest that touchmay play more of a role in the development of emotional and behaviouralproblems than in the evolution of adaptive social behaviour for low birthweight children. The nurturing quality of touch seems particularly importantin the prevention of later problems for all low birth weight children. Incontrast, frequent touching appears to place infants at risk for increased prob-lems. This negative relationship between frequent touch and emotional/behavioural problems was strongest for infants who were less socially respon-sive in their early months of life. At the same time, complex maternal touchseemed to facilitate superior adaptive social behaviour for these less respon-sive infants. The very modest and/or nonexistent relationships betweenspecific properties of maternal touch and a mother’s other caregiving be-haviour suggest that the contribution of touch to the infant’s psychosocialdevelopment may be a distinct part of the mother’s constellation of caregiv-ing rather than simply a marker of her overarching style.



Nurturing Touch as an Enhancement to Self-Regulation

Children of mothers who used more nurturing touch had significantly feweremotional and behavioural problems at 2 years of age, especially fewer internal-izing problems such as depression and anxiety. In contrast, children of motherswho showed evidence of any harsh touch during the feeding exhibited moreproblems. Lastly, there was a trend toward better adaptive ‘daily living skills’for children receiving high amounts of nurturing touch than for childrenreceiving any form of harsh touch. It is important to note, however, that thesmall size of the subsample using harsh touch limits generalizability of theirdata.

Our findings implicate nurturing touch as a protective factor for the child,potentially because of its contribution to the infant’s development of self-regula-tory skills. There is growing interest in the idea that many of the social andemotional problems plaguing the low birth weight child are the result of deficitsin self-regulation of affect and behaviour. Self-regulation develops in a sophisti-cated progression throughout childhood, but its early foundations appear tostem from internalization of the felt experience of maternal regulation of theinfant’s emotional reactivity (Perry et al., 1995; Schore, 1998). Hofer (1987, 1993)argues that normal, maternal tactile stimulation constitutes an early stage indevelopment of psychological self-regulation, the absence of which may haveprofound repercussions for internal regulatory development later in life. Forinstance, the child may incur later regulatory failures in behavioural control oremotional stability, manifested in outcomes such as rage, paralysing anxiety,despair, or violence.

Numerous studies have shown that soothing, comforting touch, in particular,plays an important role in reducing infant stress and regulating emotionaldistress (Stack and Muir, 1990; Michelsson et al., 1996; Pelaiz-Nogueras et al.,1996), often with a potency that is superior to vocal or visual communication(Grossman et al., 1985; Korner, 1990). In contrast, when a mother is physicallyunavailable, emotion dysregulation can occur, resulting in disorganization ofaffect, sleep and activity (Field, 1987, 1994). Animal models have also shownthat maternal tactile stimulation regulates an infant’s activity level, vocalization,sleep–wake states, neurochemical and endocrine systems (Kehoe and Blass,1986; Hall and Oppenheim, 1987; Hofer, 1987; Levine and Stanton, 1990; Liu etal., 1997). Even postnatal handling and petting of animals by humans appears toreduce emotional reactivity in later life, enhancing the animal’s ability to copeeffectively with stressful tasks or unusual, novel conditions (Meaney et al., 1990;Gschanes et al., 1995). Our results resonate with these animal studies, suggestingthat nurturing touch may serve as a protective factor for human infants in theirdevelopment of regulatory strategies for coping with their emotions and theirenvironment. Our data show that infants who receive less nurturing touch andmore harsh touch show signs of more depression, anxiety and withdrawal byage 2. These findings are in concert with other human research which hasindicated a link between the felt satisfaction from touch received as a child andboth depression and later ability to cope with stress as an adult (Cochrane,1990).

Diverse Touch as a Source of Enrichment

Complex or diverse maternal touch had no impact on psychosocial outcomes formore socially competent infants. But, for infants who were less responsive totheir caregivers early in life, the diversity of maternal touch was linked to better



adaptive outcomes at 2 years of age. Less responsiveness is typically noted inbabies with more CNS immaturity (Lester et al., 1985) so it is highly likely thatthe overall sensory and neural sophistication of this group of infants waslimited. Specifically, there is evidence of abnormalities in synapse formation,development of neuronal connections and myelinization in higher risk, lowbirth weight infants (Mutch et al., 1993). Under such conditions, the earlierontological development of skin sensations may give touch special importancein providing external input to the baby about the world. In our study, morediverse touch involved the use of a broad array of tactile gestures by mothers aswell as contact with a wide variety of the infant’s body parts. This enrichedstimulation may provide less responsive infants (whose visual and auditorysystems are not well developed) with an essential foundation of experienceotherwise not available. Indeed, research has shown that infants transfer muchof the information learned through touch to visual and auditory knowledge asthey develop (Hatwell, 1987; Helders et al., 1988; Pineau and Streri, 1990; Rose,1990).

Our results imply that more vulnerable infants (with less ability to respond totheir environments visually or motorically) may rely, to a greater degree, on thetactile stimulation provided by mothers for much of their environmental enrich-ment. In contrast, the robust infant, possessing a more adequate perceptualapparatus for extracting and integrating information about the world, would beless dependent on the variety and diversity of maternal touch. These findingssupport other studies documenting the role of environmental stimulation inrefining immature neural circuitry (Katz and Shatz, 1996). Diverse maternaltouch may enhance such neural development, with implications for improve-ment in any cerebral dysfunction that could limit the child’s adaptive capacityand personal functioning later in life. In particular, our data suggest its effectson essential living skills such as bowel and bladder control, independent eating,and taking initial responsibility for toys and clothing.

Frequent Touch as a Risk Factor

Frequent touch was linked to more problems (primarily externalizing disorders)for all infants in the sample. Its specific relationship to increased aggressive anddestructive behaviour raises the possibility that frequent touch is experienced bymore vulnerable infants as intrusive or unwelcome. If the frequency of maternaltouch is not modulated consistently, the child may eventually (a) come to seethe world as an insensitive place, and (b) develop regulatory failures inemotional and behavioural control. Our results demonstrate that less responsiveinfants were particularly susceptible to frequent touch. For this group of babies,frequent touch accounted for an additional 6% of the variance in their likelihoodof developing aggressive or destructive behaviour by age 2. These findings mayagain underscore the fragile and underdeveloped nervous systems of the lessresponsive babies. Frequent touch may especially overload their neural appara-tus, impeding their ability to process the myriad stimuli to which they areexposed. Less responsive infants with more complicated courses show both adiminished ability to modulate their arousal (Aylward et al., 1984) and substan-tial avoidance of interaction (Bennett, 1997) in an apparent attempt to managetheir arousal. In addition, the painful probing and pricking experienced by veryhigh risk infants in the course of their medical care may create some tactileaversion in these children which impedes their ability to effectively integratetactile input later on (DeMaio-Feldman, 1994).



Less responsive infants have fewer interactive skills available to communicateto their mothers any hyperarousal or aversion they may experience from thetouch they receive. They have limited access to more sophisticated regulatorystrategies such as gaze aversion or crying to help repair an intrusive oroverstimulating interaction. This situation could be doubly problematic in lightof the fact that mothers of smaller and less responsive infants often compensatefor the baby’s inactivity by high levels of engagement and frequent stimulationof the infant (Millot et al., 1988; Spiker et al., 1993).

Touch and the Caregiving Gestalt

Considered as a whole, our results for the second aim provide minimal supportfor the hypothesis that maternal touch is a somewhat transparent reflection ofthe overarching caregiving style used by a mother. We found no associationbetween either frequent or diverse touch and a mother’s other caregivingbehaviour. The small number of mothers using any harsh touch limited thestatistical power necessary to detect subtle relationships but we found noassociation between harsh touch and a mother’s rejection of her infant or herresponsiveness to distress. Our finding that mothers who used harsh touch alsoused nurturing touch with their infants suggested that these mothers may be‘tactually expressive’ for a spectrum of positive and negative affect. This mayexplain their trend toward higher scores for socioemotional growth fosteringbehaviour with the infant because the NCAST social-emotional growth fosteringsubscale assesses the affective domain of the mother’s caregiving interaction(including such behaviours as varying the pitch and tone of the voice orshowing changes in facial expression toward the infant). However, the subscalealso assesses interactional warmth toward the infant, a behaviour that isconceptually at odds with slapping, hitting or pinching the child. But, as notedearlier, mothers who used harsh touch did so on average only 2% of their totaltouch, leaving ample time for a substantial amount of nurturing touch as well.

Our one set of findings that may implicate maternal touch as a marker of themother’s overarching caregiving style was related to nurturing touch. For moreresponsive infants, there was a modest relationship between use of nurturingtouch and maternal warmth. However, this association did not exist for lessresponsive babies. The group specificity of the association and its relativelysmall effect size would suggest that the two variables may naturally co-occur aspart of caregiving but without any clear redundancy or interdependence. Ourresults showing a relationship between less optimal caregiving behaviour andthe absence of any nurturing touch toward the infant provided the strongestsupport for touch as a marker. This finding suggests that a certain basicmaternal warmth and concern for the child’s socioemotional well being maywell be indexed by some equally basic display of nurturing touch.

In the main, our data support the view that specific properties of maternaltouch may play a semi-autonomous role in the infant’s development whileconverging to some extent with other related aspects of the caregiving gestalt.This hypothesis has some support from previous research. For instance, Polanand Hofer (1999) provide evidence that different sensory modalities may playunique and essential roles in the development and survival of infants of otherspecies, including forms of tactile stimulation. They propose a tightly specifiedmultisensory complex with distinct roles for various sensory systems whichshape the developing physiology and behaviour of the infant. Other researchhas also suggested a potentially autonomous role for touch in adult– infant



communication (LePage and Stack, 1992; Dickson et al., 1997; Pelaiz-Nogueras etal., 1996). While further study is necessary to elaborate the meaning of touch ina mother’s overall constellation of caregiving, our findings indicate that it ispremature to assume touch is simply a marker for other caregiving attitudes orbehaviour.

Conclusion

Prior to any application of our findings, the results of this research must bereplicated and reinforced by clinical trials that test the effects of specificprogrammes of tactile stimulation on a variety of psychosocial parameters atregularized points throughout the child’s development. It will also be importantto examine more critically the various ways in which touch may interact withother caregiving behaviour to influence psychosocial outcomes. However, thesefindings give preliminary credence to the importance of both the quality andquantity of touch experienced by low birth weight infants during their earlymonths. Our findings support invaluable animal research regarding the role oftactile stimulation (especially nurturing touch) as a potential regulator of emo-tional and behavioural homeostasis in the infant. They also give piquancy toprevious theories regarding the developmental importance of an enriched tactileenvironment, especially for more vulnerable, less responsive low birth weightinfants. And for these less socially competent infants, the results speak to anurgent need for careful assessment of their individual reactions to the overallamount of touch they receive. Family interventions to sensitize parents to thepotential effects of touch may inspire more optimal mental health and socialadaptation for their child in the long term.

ACKNOWLEDGEMENTS

This research was funded by the US National Institutes of Health, NINR, cR01NR02698-5.

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