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The Effects of Prematurity on the Social and Emotional Development of School Age Children: Discussion

By Michele Bell

Overall, the results of the current study support the hypothesis that the prolonged separation of mothers from their premature infants negatively impacts on mother's mental state following the discharge of her infant. Furthermore, evidence was found for the prediction that mother's depressive state, following the discharge of her infant, had a direct effect on later childhood functioning. That is, increased levels of depression were found to be directly associated with an increase in internalising, externalising and poorer social behaviours amongst their children. The overall aim of the current study was to investigate the ego maturity of premature children and whether or not the prolonged separation of infants from their mother's negatively impacts upon the developing ego as represented by Mahler, Pine and Bergman (1975), concerning the psychological birth of the human infant.

The prediction that the prolonged separation of infants from their mothers would negatively impact on children's ego development over and above mother's emotional state was supported. In addition, some support was found for the hypothesis that ego maturity mediates the relationship between mother's depression and premature children's poorer social functioning. However, the hypothesis that poor ego maturity would mediate the relationship between mother's negative emotionality and their child's internalising behaviours failed to be supported in the current study. The prediction that externalising behaviours would not be associated with either ego maturity or prolonged hospital care, was also supported by the results of this study. Finally, the prediction that social problems would be related to the development of attention difficulties in premature children was also supported.

Premature mothers emotional life

The findings that the separation of mothers from their premature infants combined with an increase in maternal caring anxiety leads to depressive mood was consistent with Feldman, Weller, Leckman, Kuint and Eidelman (1999), investigation into the psychological processes of a mothers mental life following the birth of a premature infant. Guided by Winnicott's (1956) psychoanalytical account of a mother's mental life during the bonding stage, Feldman et al. reported that mothers who were separated for brief periods of time displayed a significant increase in maternal separation anxiety. However, with prolonged separation, the mother's mental state, which is characteristic of 'primary maternal preoccupations' develops into a state of depression and ultimately limits the mother's capacity to engage in the pleasurable, relationship-building aspect of bonding. While the evidence in the current study is retrospective, the strong suggestion is that the prolonged separation of mothers from their premature infants in the early postnatal period leads to an increase in caring anxiety which in turn leads to depressive mood. Moreover, the current study assessed mothers' level of depression after the infant had returned home which suggests that the effects of prolonged separation may not be immediately reversible following the discharge of her premature infant.

Taken together these findings suggest that a highly anxious state in mother's of premature infants may indeed play some part in the causation of depressive mood following the transition from hospital to home. However, it should be noted that length of stay also directly and independently led to mother's self-reported depressive mood for reasons not explained in the model. A possible explanation for these unexpected findings may be that mothers' negative emotional state following the apparent recovery of her infant reflects further concerns about possible disabilities or other later difficulties of the infant (Minde, 2000; Goldberg & DiVitto, 2002).

The effects of mothers emotional state on premature children's development.

Regarding the findings that mother's depressive mood is directly associated with children's adverse social, internalising and externalising behaviours is also consistent with a large body of literature that documents similar behavioural outcomes in full-term children whose mothers suffer from post-natal depression (for a review see, Gelfand & Teti, 1990). However, the results of this study point to the sensitivity of premature infants' to mother's sub-clinical symptoms of depression. In the current study, 22% of mothers reported feeling 'often depressed', 30% reported only a slight increase in depressive feelings and an additional 12% of mothers reported being diagnosed with a depressive mood in the premature group. Corroborating previous research (e.g., Poehlmann & Fiese 2001), these results provide tentative support for the notion that premature children are particularly susceptible to both clinical and mild disruptions in mother's emotional state in early infancy.
Having said that, it should be noted that while mother's negative emotionality predicted some of the internalising, externalising and poorer social functioning of premature children, the extent of the contributions was minimal on all three outcome variables (see Figure 5). As argued in this thesis a more complex model that takes into consideration the particular characteristics of the child is needed in order to provide a more complete understanding into the effects of prematurity on the psychosocial development of prematurely born children.

The effects of prematurity on children's ego development.

Indeed, another set of events which negatively affects premature infants psychological development appears to be the prolonged separation the infant experiences from his or her nursing mother. That is, the prediction that prolonged hospital care would negatively impact on children's ego development, regardless of mother's emotional state, was supported by the results of this research. Consistent with Eckerman and Oehler (1992) observations, the premature neonate appears to be a highly organised entity, with interpersonal capacities operating during the neonatal period. In the current study, the mean length of hospitalisation for premature infants was 81 days, which according to Object Relations theory concerning the psychological birth (Mahler, Pine & Bergman, 1975) indicates that many of these infants may have reached the symbiotic stage of psychological development during their hospital stay.
Briefly, normal symbiosis is followed by the lifting of the innate stimulus barrier that protected the newborn from internal and external stimuli in the first few weeks of extrauterine life. Symbiosis develops through the predicability of a nursing mother alleviating tensions from within such as hunger (Mahler, Pine & Bergman 1975). Therefore, the mother's availability and responsiveness to her infant, affects the formation of internal object representations that theoretically, govern much of the child's later social behaviour.

In the case of the premature infant, this developmental stage occurs under very different circumstances; in a newborn intensive care unit (NICU), and in the face of intrusive and often stressful medical and nursing procedures (Eckerman & Oehler, 1992). Furthermore, mothers are acquainted with their infants for relatively brief periods, largely separated in time and not necessarily related to feeding or nurturing the infant (Field, 1990; Goldberg & DiVitto, 2002). Therefore, the predicability of the nursing mother alleviating tensions from within is absent for the premature infant during their hospital stay.
According to Mahler, Pine and Bergman (1975), in cases where the symbiotic process has been disturbed, the process of separation individuation, which results in coherent self-other representations, may also be delayed or disturbed. Failure to acquire adequate internal self-object representations leave their mark in the form of strong dependency needs, enmeshment and poor interpersonal functioning (Behrends & Blatt, 1985; Levine, Green & Millon, 1986; Murray, 1991). In the current study, premature children did indeed have weaker ego maturity when compared to those children who remained in proximity to their nursing mother. Poorer ego maturity resulted in premature school aged children feeling overly dependent on significant others who were also felt to be less responsive and assessable to their needs. Furthermore, the current results, which suggest that ego maturity partially mediated the relationship between mother's negative emotionality and children's poor social behaviours supports the argument presented in this thesis regarding the effects of prolonged separation on children's psychosocial development. That is, ego maturation during the hospital stay rather than simply mother's negative emotionality following the infant's discharge, would appear to play an important role in the development of premature children's adverse social functioning. These findings lend strong support to the traditional Object Relations view concerning the primacy of early social experiences with the nursing mother in the development of ego maturity and later relational functioning.

In addition, these findings are consistent with Avery and Ryan (1988) who report that poor ego maturity is predicative of problematic social functioning in early childhood. However, there were some findings which contradicted this idea. For example, mother's depressive mood was also directly associated with the poorer social functioning of children over and above children's ego maturity. In addition, ego maturity failed to mediate the relationship between mother's negative emotional state and children's later internalising problems as anticipated. Rather, the internalising and poor social behaviours of premature children, revealed a direct association with mother's depressive mood.

A methodological explanation for this unexpected pattern of results may be that the ego measure (AORI) utilised in the current study failed to tap into the emotional problems representing depression and anxiety in children. In the present study, items representing emotional disturbances were modified or excluded from the study to ensure their applicability to children aged between 9 and 12. This may have influenced the absence of an indirect effect through ego maturity due to the lack of items tapping into emotional disturbances in children. Thus, methodological issues may have accounted for these results.
However, there could also be alternative theoretical accounts for the present study's direct link between mother's affective state and children's social and emotional development. For example, depressed mothers have been found to be less likely to establish social interactional patterns that are effective in the transformation of an infant's negative affect into positive affect (Tronick, 1989; Field, 1992). Furthermore, mothers of relatively high-risk premature infants have been shown to be less responsive to their infant's interactional cues when compared to relatively healthy premature mother-infant dyads. That is, mothers look and smile less at their high-risk premature infants (DiVitto & Goldberg, 1979) and engage in less face to face contact (Minde, Perrotta, Marton, 1985). The origin of these interactional differences is thought to be related to the premature infant's inability to provide clear affective and behavioural cues (Field, 1979). As previously mentioned premature infants are less socially responsive and harder to soothe when compared to their full-term counterparts (Goldberg & Divitto, 2002; Minde, 2000; Field, 1979). Failure to attune to an infant's cues may lead to mother's affective withdrawal, which in turn could further inhibit a child's ability to feel positive when dealing with his or her changing social environment. From a social-learning perspective therefore, premature parents may create an environment in which their children learn poorer social skills and internalising behaviours. This in turn may lead to later poor psychosocial functioning (Mc Adams, 2001).

Consistent with previous research (e.g., Sykes et al, 1997; Schothorst and van Engeland, 1996), the hypothesis that the impaired social functioning of premature children would predict later attention problems was supported in the current study. That is the poor social functioning of prematurely born children explained 25% of the variation in attention problems. These findings imply that the poor social functioning of children, who were hospitalised for prolonged periods, may well be an indication of future attention problems that could be conceptualised as a general immaturity relating, at least partially, to ego development.

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