76-9956DERRICK, Sara Marian, 1918*

INFANTS BORN TO NARCOTIC AND NONNARCOTIC ADDICTED WOMEN: A STUDY OF THEIRNEUROLOGICAL STATUS AT BIRTH AND RESPONSE TO AN INFANT STIMULATION PROGRAM IN THE FIRST THREE MONTHS OF LIFE.The Ohio State University, Ph.D., 1975 Education, psychology

Xerox University Microfilms # Ann Arbor, Michigan 48106

THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED.

©Copyright by Sara Marian Derrick

1975

INFANTS BORN TO NARCOTIC AND NONNARCOTIC ADDICTED WOMEN:

A STUDY OF THEIR NEUROLOGICAL STATUS AT BIRTH AND

RESPONSE TO AN INFANT STIMULATION PROGRAM

IN THE FIRST THREE MONTHS OF LIFE

DISSERTATION

Presented in Partial Fulfillment of the Requirements for

the Degree Doctor of Philosophy in the Graduate

School of The Ohio State University

BySara Marian Derrick, B.A., M. Ed

The Ohio State University

1975

Reading Committee: Approved By

Julia Dalrymple, Ph.D. William Dowling, Ph.D. Jean D. Powers, Ph.D.

Claribel Taylor, Ph.D. Ellen R. Hock, Ph.D. fa

School of Home Economics Department of Family Rela­tions and Human Development

ACKNOWLEDGMENTS

Many persons have provided resources to make this study possible.

My first appreciation is extended to Dr. Ellen R, Hock, who first

brought to my awareness the exciting field of infant development and

who assisted in guiding my program through its entirety. Appreciation

is further extended to Dr. Claribel Taylor and to Dr. Julia Dalrymple

who patiently provided direction in formulating specifics in this study.

I wish also to thank my reading and examining committee who provided

much encouragement to me.

My most heartfelt thanks are extended to persons at The Ohio

State University Hospitals— Dr. Elizabeth Ruppert, Pediatrician, who

helped me develop facility in using medical data in this study,

administered neurological examinations, provided medical follow-up to

the infants and advice to their parents. Thanks to Mrs. Chris Harter,

Pediatric Nurse, who promptly alerted me to availability of subjects,

and who helped motivate the parents, to participate in the study and

to seek medical follow-up for their infants. Appreciation is also

extended to the other nurses at The Ohio State University for their

kindness in sharing their work areas with me in order that I might

have space for assessing the infants.

Thanks are also extended to Dr. Jean D. Powers and Ms. Linda C.

Rolfes, Department of Preventive Medicine, for providing statistical

sophistication for analysis of masses of data in this study, and to

Dr. Mary Anne Trause, of Rainbow Children’s Hospital, Case Western

Reserve University Hospital, Cleveland, Ohio, who guided me through

refinement of techniques for administering the Brazelton Scale.

The generosity and cooperation extended by staff of Vita Drug

Treatment Center, Project Lynden, and Traynor House, Columbus, Ohio

will never be forgotten.

Appreciation is extended to the typist, Mrs. Nancy V. Davidson,

for her thoroughness and diligence in completing the manuscript.

Special thanks are extended to the parents of the infants who

permitted me to enter their homes on so many occasions and work with

them. Without their cooperation this study would not have been possible.

Finally, sincere gratitude is extended to my husband, Bill, who

patiently made many sacrifices in order that this study might be

brought to fruition.

iii

VITA

January 4, 19 1 8............... .. Born - Cuthbert, Georgia

1956 .........................B.A., Howard UniversityWashington, D. C,

1957 - 1967 ............... Teacher, Sandusky Public Schools,Sandusky, Ohio

1959............................ M.Ed., Bowling Green State University,Bowling Green, Ohio

1963 - 1972.................... Director, Ebenezer Day Nursery,Sandusky, Ohio (Part-time)

1967 - 1968.................... Director, Remedial Reading,Sandusky Public Schools, Sandusky,Ohio

1968 - 1969 ................. Intern School Psychologist,Betty Jane Memorial Rehabilitation Center, Tiffin, Ohio

1969 - 1974 ................... Psychologist, Sandusky Public Schools,Sandusky, Ohio

1972 - 1973 . ........ . . . . . Graduate Research Associate,Department of Pediatrics,The Ohio State University Hospitals, Columbus, Ohio

1975 . . . . . . . . . . . . . . Instructor, Bowling Green StateUniversity, Bowling Green, Ohio

Major Fields of Study:

Family Studies and Child Development - Dr. Ellen HockDr. Claribel Taylor

Developmental Psychology - Dr. George Thompson

Early Childhood Education - Ms, Isabel Miller

iv

TABLE OF CONTENTS

page

ACKNOWLEDGMENTS......................................... U

V I T A ................................................... v

LIST OF T A B L E S ........................................ ix

LIST OF FIGURES ....................................... xii

Chapter

I INTRODUCTION ................................... 1

Background for the Study ..................... 1Significance of the Study ..................... 3Statement of the Problem ..................... 4Objectives............... 4Hypotheses ..................................... 7Limitations in the Study ....................... 9Relationship to a Larger Research Project . . . . 10Glossary....................................... 10Plan of S t u d y ................................. 13

II REVIEW OF LITERATURE............................. 15

Maternal Complications Associated withNarcotic Addiction ........................... 15Treatment Efforts for Narcotic Addiction . . . 18Neonatal Complications Associated withNarcotic Addiction ....................... 19

Onset of Infant Withdrawal Symptoms ........ 23Problems of Diagnosis . . . . . 24Prognosis of the Addicted Mother ............ 26Care of Infants of Addicted W o m e n .......... 27Prognosis of Infants of NarcoticAddicted Women ........................... 28

Developmental Outcome of Infants Bornto Narcotic Addicted Women............... 29

Theoretical Views of Family Functioning ........ 33Intervention Programs ......................... 36Studies of Infant Attention ................... 40

Studies of Attention to Auditory Stimuli . . . 41Studies of Attention to Visual Stimuli . . . . 42Studies of Attention to Stimuli that Move . . 46

v

page

Studies of Infant Responses to TactileExperiences......................... . • 48

Infant Assessment ........................... 50Apgar Procedure ................ . . . . . 50Neurological Evaluation ............... . 50Brazelton Neonatal Behavioral AssessmentScale . . . . . . . . . . . . . . . . . . 51

Bayley Scales of Infant Development . . . . 55Maternal Assessment . ..................... 57

The Caldwell et al. Inventory of HomeStimulation........................... 57

Ainsworth Maternal Care Scales........... 59Parent Counselor Home Visit Report ........ 61Infant Care Inventory................... 62Two Factor Index of Social Position . . . . 63

Summary..................................... 64

III METHOD......................................... 65

Research Design ............................. 65Subject Selection ....................... 65Case Histories of Addicted Women.......... 66

Marital Status ....................... 66Residential Characteristics . . . . . . 66Number of Children................... 69Extent of Child Care Provided for themby O t h e r s ......................... 69

Educational Level ................... 69Reason for Leaving School ............ 69Drug Experience..................... 69Receptivity to Intervention Program . . 70

Data Collection . . . . . . . . . . . . . . . . 71Intervention and Data Collection .......... 71

Phase I ............................. 71Phase I I ............................. 73Phase I I I ........................... 74

Intervention Materials . . . . . .......... 86Assessment Instruments ................... 87

Data Analysis . . . . . . . . . . . . . . . . . 87Amiel-Tison Neurological Evaluation of theMaturity of Newborn Infants ............ 88

Brazelton Neonatal Behavioral Assessment Scale 88 Bayley Scales of Infant Development . . . . 88Maternal Assessment ..................... 89Statistical Methods Employed .............. 89Usefulness of Instruments Utilized

in this S t u d y ......................... 91

vi

page

IV RESULTS.......................................... 93

Presentation of Results....................... . 93Intervention Results ........................... 129Feasibility of Planning and Implementinga Home-Based Intervention Program .............. 130

V SUMMARY AND IMPLICATIONS ......................... 131

Appendix

I Neurological Evaluation of the Maturity ofNewborn Infants ................................. 139

II Brazelton Neonatal Behavioral Assessment Scale . . . . 141

III Inventory of Home Stimulation...................... 152

IV Ainsworth Scale MA-1 Mother's Perceptionof B a b y ......................................... 162

V Ainsworth Scale MA-2 Mother's Delight in Baby . . . . 165

VI Ainsworth Scale MA-3 Mother's Acceptanceof B a b y ......................................... 168

VII Ainsworth Scale MC-1 Mother's Availabilityto B a b y ............•............................ 171

VIII Ainsworth Scale MC-3 Amount of InteractionOffered by M o t h e r ............................... 175

IX Ainsworth Scale MC-4 Appropriateness ofMother's Initiation of Interaction ............. 178

X Parent Counselor Home Visit Report ................... 182

XI Infant Care Inventory ...................... 187

XII Hollingshead Two Factor Index of Social Position . . . 196

XIII Parent Interview Report ............................ 210

XIV Help a Baby B o o k l e t............................... 214

XV Mother's Compliance with Medical Appointmentsand Suggestions................................. 223

XVI Tables 21 - 26 Summary of Results of Analyses ofVariance on Brazelton Items 3, 6, 7, 9, 20 and 26. . 227

vii

pageXVII Table 27a Summary of Significantly Different

Group Means on Those Items Where Time Was Significant as a Main Effect--No Interaction Significance..................................... . 235

Table 27b Summary of Significantly Different Time Means for Those Analyses of Variance on Items Where Group and Time Were Significantas Main Effects--No Interaction Significance ........ 235

BIBLIOGRAPHY ............................................... 236

viii I

LIST OF TABLES

Table page

1. Characteristics of the Sample..................... 67

2. Schedule of Data Collection....................... 72

3. Summary of Intervention........................... 85

4. Summary of Differences by Fisher ExactProbability Test in Gestational Ages of Newborn Infants of Addicted and Nonaddicted Mothers Determined by Items of the Amiel-Tison Neurological Evaluation of Maturity of Newborn 95Infants ...........................................

5. Summary of Results of Analysis of Variancefor Twenty-Seven Brazelton Behavioral Items ........ 97

6. Summary of Significance of Effects for GroupX Time for the Twenty-Seven Behavioral Items . . . . 98

7. Summary of Statistically Different Group Means for the Group X Time Analysis of Variance on Items Where Only Group Was Significant as aMain Effect.................................. 99

8. Summary of Results of Analysis of Variance with Brazelton Item l--Response Decrementto L i g h t ......................................... 100

9. Summary of Group Means for Those Items When Differences Were Significant With BrazeltonItem 14--Cuddliness . . . . ....................... 105

10. Summary of Analysis of Variance for BrazeltonItem 15--Pull To S i t ............................. 106

11, Summary of Results of Analysis of Variance For Brazelton Initial State and Predominant StateItems • 108

11a. Summary of Results of Group X Time Analysis ofVariance for Brazelton Initial State Items . . . . . 109

ix

page

112

113

114

115

117

118

120

122

123

123

228

229

230

Number or Infants in Each Group Receiving a Score of Two With Brazelton "Elicited Responses" at Four Age Periods (Three Days, T,; One Week, T2;Two Weeks, T^; Three Weeks, T^) Analyzed WithWilcoxon Signed Rank T e s t ..............................

Summary of Results of Analysis of Variance withBayley Scales of Infant Development--Mental Scale . . . . .

Summary of Results of Analysis of Variance of Visual Following Skills with Bayley Scales of Inf an t Development.......................................

Summary of Results of Analysis of Variance with Bayley Scales of Infant Development— Psychomotor Development............................................

Differences Between Scores of Addicted and Nonaddicted Women with Hock Infant CareInventory Analyzed with Mann Whitney U Test ..............

Differences Between Scores of Addicted and Nonaddicted Women with Ainsworth MaternalCare Scales Analyzed with Mann Whitney U Test ............

Differences Between Scores of Addicted and Nonaddicted Women with Caldwell et al.,Inventory of Home Stimulation Analyzed withMann Whitney U Test .....................................

Scores of Addicted and Nonaddicted Women withWright et al., Parent Counselor Home VisitReport--Analyzed with Mann Whitney U T est...............

Scores of Addicted and Nonaddicted Women withRespect to Compliance with Medical Appointments . . . . . .

Scores of Addicted and Nonaddicted Women withRespect to Compliance with Medical Suggestions ..........

Summary of Results of Analysis of Variance with Brazelton Item 3— Response Decrement to Bell ............

Summary of Results of Analysis of Variance with Brazelton Item 6— Orientation Response--Inanimate,Audxtory . . . . . . . . . . . . . . . . . . . . . . . . .

Summary of Results of Analysis of Variance with Brazelton Item 7--0rientation--Animate Visual ............

x

page

24. Summary of Results of Analysis of Variance with Brazelton Item 9-~0rientation Animate--Visualand Auditory......................... 231

25. Summary of Results of Analysis of Variance withBrazelton Item 20--Activity (Alert States) ............. 232

26. Summary of Results of Analysis of Variance withBrazelton Item 26--Hand to Mouth Facility ............. 233

27a. Summary of Significantly Different Group Means on Those Items Where Time was Significant as aMain Effect— No Interaction Significance ............... 235

27b. Summary of Significantly Different Time Means for Those Analyses of Variance on Items Where Group and Time Were Significant as Main Effects-- No Interaction Significance............. 235

xi

76

77

78

79

80

81

82

83

84

96

102

104

106

LIST OF FICURES

Materials Used as Auditory Stimuli .........

Materials Used as Visual Stimuli ...........

Materials Used as Visual Stimuli ...........

Materials Used as Visual Stimuli ...........

Materials Used as Visual Stimuli ...........

Materials Used as Visual-Movement Stimuli . ,

Materials Used as Visual-Movement Stimuli . ,

Materials Used as Visual-Movement Stimuli . .

Materials Used as Tactile Stimuli ..........

Summary of Means of Addicted and Nonaddicted Infants with 27 Brazelton Items ..........

Group Means of Brazelton Item 5, at Four Age Periods .................................

Group Means of Brazelton Item 14, at Four Age Periods .................................

Group Means of Brazelton Item 15, at Four Age Periods............... ................

xii

CHAPTER I

INTRODUCTION

Background for the Study

Case histories of infants born to narcotic addicted women have

been reported for nearly one hundred years (Coodfriend et al. 1956).

Lin-Fu (1969) noted that a review of the literature pertaining to

narcotic addicted women occurred approximately a decade ago and served

as impetus for further studies of infants born to narcotic addicted

women. Lin-Fu (1969) commented on findings from various studies.

All those (studies) indicated that narcotic addiction during pregnancy poses a dual problem: not only are the womenhigh-risk obstetrical patients, but most of their babies are born addicted and, unless diagnosed early and managed pro­perly, suffer a formidable mortality and morbidity rate.

The extent of narcotic addiction may not bo fully known since

cany narcotic users fail to identify themselves as such (Trussell 1971

£i Zelson et al. 1973). Cobrinik et al. (1959) found that in the city

of New York alone during a one year period more than 800 pregnant

addicts registered with the Department of Narcotic Control and that

number would probably result in more than 800 potentially addicted

newborn infants. Zelson et al. (1973) estimated the number of narcotic

addicts in the United States between 100,000 and 200,000. That figure

represents an increase from 64,011 reported by Lin-Fu (1969) and a

greater increase from that reported by Hill and Desmond (1963).

1

The age distribution of narcotic addicts is noteworthy from the

standpoint of reproduction (Lin-Fu 1969), especially since several

physicians (Hill and Desmond 1963; Blinick et al. 1969; Reddy et al.

1971; Pierson et al. 1972; Wilson et al. 1973 and Zelson et al. 1971)

reported an age range of addicted women between twenty and forty years,

while Levy (1967) noted use of drugs by adolescents. Such an age

range may suggest that many infants may be born to narcotic addicted

women. The phenomenon of narcotic addiction and its impact on the

female addict are manifold.

Financial cost for maintaining a supply of narcotics may vary

within a range from two dollars to one hundred eighty dollars daily,

with the female addict engaging in prostitution and shoplifting to •

support her purchase of narcotics until advanced stages of pregnancy

occur (Statzer and Wardell 1972). Prostitution is noted to carry a

high risk of syphillis and other diseases. Finnegan and Macnew (1974)

noted that the addict's diet is poor and consists of that which she

can obtain in vending machines--candy bars, potato chips, pretzels,

an occasional sandwich and soft drinks. Her resulting malnutrition not

only affects her well-being but also that of her infant. Levy (1967)

noted that narcotic users may supplement their income by selling

narcotics to others. Blinick et al. (1967) commented regarding further

problems of narcotic addicts.

In addition to the influence on the psychological and social processes, narcotic addiction is known to have profound effects on the physiological processes as well. The narcotic addict spends most of her time unable to function. She experiences intermittent periods of normal alertness and well being, but for the bulk of her time the addict is "high" or "sick." The "high" or euphoric state finds the addict sedated, tranquilized, absorbed in herself and lost to responsibility. The "sick"

or abstinent state is characterized by craving for narcotics with malaise, nausea, perspiration, tremors and cramps.. . . The adict oscillates between "high" and being "sick" with little time to function.

Because of their life-styles and because of fear of calling

attention to their drug habits some pregnant addicts are reported to

maintain a low standard of self care and fail to seek prenatal inter­

vention. Davis and Chappel (1974) reported that 75 percent of addicts

never visit a physician during their pregnancy periods and have a high

incidence of medical complications.

Sussman (1963) noted that the addict mother is often first seen

in labor and her addicted infant is frequently regarded as a diagnostic

problem until a history of maternal addiction is established. Krause

(1958) noted that only four of a group of 18 women received

prenatal care and that on admission to a hospital some of the women

experienced infected ulcerating veins. Perlmutter (1967) studied

22 heroin addicted women of whom four attended prenatal clinic

for a total of 14 visits; two registered but failed to maintain

their appointments. Untreated positive serologic tests for syphillis

ware found in five of the patients.

Significance of the Study

Evidence is available that Americans are becoming increasingly

cognizant of social problems that accompany narcotic addiction by some

members of American society. Much of that evidence is reflected in

efforts by persons in the medical profession for implementing procedures

designed to aid narcotic addicted persons. In the meantime newborn

infants of narcotic addicted women, because of reported neonatal

4characteristics, seem to represent a high-risk group and are cause

for concern upon their return in many instances to physically deprived

environments. Concern centers on whether or not infants born to

narcotic addicted women escape the environment that produced their

mothers and whether a short-term intervention program may make a

contribution toward motivating the mother to provide quality caretaking

skills to her infant. Effort that may be directed toward improving

the functioning of mothers of such infants, as well as providing

medical and cognitive intervention, may serve as contributions not only

toward helping an immediate need but toward improving the life-style

of addicts over that which was reported by Blinick et al. (1967).

Statement of the Problem

The purpose in this preliminary study was to compare the develop­

ment of infants born to narcotic women to infants born to nonnarcotic

addicted women, as preliminary to a subsequent study, and to describe

family dynamics of addicted women in this study and their drug history.

In addition, the purpose in this study was to document whether

changes in infants' behavioral characteristics were evident after pre-

and post-tests of mother-infant pairs who participated in an interven­

tion program which emphasized educational activities that involved

medical and cognitive approaches. A further purpose was to examine

the feasibility of a subsequent study.

Objectives

The objectives in this preliminary study were:

1. To determine if there is a difference between neurologic

maturity at birth, of infants born to narcotic addicted

women (as assessed by the Ameil-Tison Neurological Evaluation

of the Maturity of Newborn Infants), and neurological maturity

at birth, of infants born to nonnarcotic addicted women (as

assessed by the Ameil-Tison Neurological Evaluation of the

Maturity of Newborn Infants).

To determine if there is a difference between performance

with the behavioral items, state items and "Elicited

Responses" of infants born to narcotic addicted women (as

assessed by the Brazelton Neonatal Behavioral Assessment

Scale) and performance with the behavioral items, state items

and "Elicited Responses" of infants born to nonnarcotic

addicted women (as assessed by the Brazelton Neonatal Behavioral

Assessment Scale), at four age periods (three days, one, two

and three weeks).

To determine if there is a difference between Mental Develop­

ment (as assessed with the Bayley Scales of Infant Development)

of infants born to narcotic addicted women and Mental Develop-

ment (as assessed with the Bayley Scales of Infant Development)

of infants born to nonnarcotic addicted women at two age

periods (one month 24 days, and three months).

To determine if there is a difference between Visual Following

skills (as assessed with the Bayley Scales of Infant Develop­

ment) of infants born to narcotic addicted women, and Visual

Following skills (as assessed with the Bayley Scales of

o

Infant Development) of infants born to nonnarcotic addicted

women, at two age periods (one month 24 days, and three months).

6. To determine if there is a difference between narcotic

addicted women and nonnarcotic addicted women with respect

to their feelings of competency for providing infant caregiving

skills, as assessed with the Infant Care Inventory.

7. To determine if there is a difference between narcotic addicted

and nonnarcotic addicted women with respect to changes in

characteristics of mothering derived from pre- and post-tests

(assessed with Ainsworth Scales--perception of, delight in and

acceptance of baby; mother's availability to the baby, amount

of interaction offered by the mother and appropriateness of

the mother's interaction with the baby); also assessed with the

Caldwell et al. Inventory of Home Stimulation.

8. To determine if there is a difference between narcotic addicted

and nonnarcotic addicted women with respect to their acceptance

of home training provided by a parent counselor (assessed with

data from Wright et al. 1970).

9. To determine if there is a difference between narcotic

addicted and nonnarcotic addicted women with respect to their

compliance with medical appointments and instructions.

10. To provide case histories of maternal characteristics which

include the following:

a) Marital status

b) Residential characteristics

c) Number of children

7d) Extent of child care provided for them by others

e) Educational level

f) Reason for leaving school

g) Drug experience

h) Receptivity to intervention program

11. To make statements regarding the feasibility of planning and

implementing a home-based intervention program directed at

contributing to enhancing quality of mothering, helping mothers

become sensitive to infant needs and helping mothers develop

caregiving skills, as preliminary to a subsequent study.

12. To make statements regarding the usefulness of instruments

utilized in this study, as preliminary to a subsequent study.

Hypotheses

Hypothesis 1: There is no difference between neurological maturity at

birth, of infants born to narcotic addicted women (as

assessed with the Amiel-l'ison Neurological Evaluation

of the Maturity of Newborn Infants) and neurological

maturity at birth, of infants born to nonnarcotic

addicted women (as assessed with the Amiel-Tison

Neurological Evaluation of the Maturity of Nev/born

Infants).

Hypothesis 2: There is no difference between performance with the

behavioral items, state items and "Elicited Responses"

of infants born to narcotic addicted women (as assessed

with the Brazelton Neonatal Behavioral Assessment Scale)

and performance with the behavioral, state items and

Hypothesis 3

Hypothesis 4

Hypothesis 5

Hypothesis 6

"Elicited Responses" of infants born to nonnarcotic

addicted women (as assessed with the Brazelton Neonatal

Behavioral Assessment Scale) at four age periods (three

days, one, two, and thre^Veeks).

: There is no difference between Mental Development (as

assessed with the Bayley Scales of Infant Development)

of infants born to narcotic addicted women and Mental

Development (as assessed with the Bayley Scales of Infant

Development) of infants born to nonnarcotic addicted

women at two age periods (one month 24 days, and three

months).

: There is no difference between Visual Following skills

(as assessed with the Bayley Scales of Infant Develop­

ment) of infants born to narcotic addicted women, and

Visual Following skills (as assessed with the Bayley

Scales of Infant Development) of infants born to non­

narcotic addicted women at age three months.

: There is no difference between Motor Development (as

assessed with the Bayley Scales of Infant Development)

of infants born to narcotic addicted women and Motor

Development (as assessed with the Bayley Scales of

Infant Development) of infants born to nonnarcotic

addicted women, at two age periods (one month 24 days,

and three months)

There is no difference between narcotic addicted women

and nonnarcotic addicted women with respect to their

9

feelings of competency for providing infant care giving

skills, as assessed with the Infant Care Inventory.

Hypothesis 7: There is no difference between narcotic addicted women

and nonnarcotic addicted women with respect to changes

in characteristics of mothering, derived from pre- and

post-tests (assessed with Ainsworth Scales~~perception

of, delight in and acceptance of baby; mother's avail­

ability to the baby, amount of interaction between

mother and infant and appropriateness of the mother's

interaction with the baby; and changes in indices of

behavior (assess with the Caldwell et al. Inventory of

Home Stimulation).

Hypothesis 8: There is no difference between narcotic addicted women

and nonnarcotic addicted women with respect to their

acceptance of home training provided by a parent

counselor (assessed with data from Wright et al. 1970).

Hypothesis 9: There is no difference between narcotic addicted women

and nonnarcotic addicted women with respect to their

compliance with medical appointments and medical

suggestions.

Limitations in the Study

Due to a limited number of eligible subjects within the city in

which this study was performed the sample size is small. Reports from

Drug Treatment Centers noted that some women who were referred to the

study experienced spontaneous abortion. Two women were lost to follow-up.

A further limitation related to the use of only one interviewer.

10It was not feasible to employ more than one person to collect data.

It would have been helpful to utilize naive evaluators who did not

become acquainted with the mothers who participated in this study. A

precaution in the study was directed toward the use of objective instru­

ments in order that biases hopefully would not intrude.

Relationship to a Larger Research Project

This study represented the preliminary phase of a longitudinal

study planned for implementation within the Department of Pediatrics

at The Ohio State University Hospitals. The longitudinal study is

designed to develop interventional techniques for training mothers or

other primary caregivers of infants who are born to narcotic addicted

women, and to assess developmental status of infants throughout their

first year of life.

Glossary

Addiction is "the state of being given up to some habit, especially

strong dependence on a drug." (Dorland's, 1974).

Analgesic is "an agent to alleviate pain without causing loss of

consciousness." (Dorland's, 1974).

Bacterial Endocarditis is "a febrile (characterized by fever)

systemic disease (affecting the body as a whole), marked by bacterial

or fungal infection of the heart valves with formation of bacteria--

or fungus-laden vegetation." (Dorland's, 1974).

Cyanosis is "a bluish discoloration, applied especially to such

discoloration of skin and mucous membranes due to excessive concentra­

tion of reduced hemoglobin (oxygen carrying pigment) in the blood."

(Dorland's, 1974).

11

Eclampsia is "associated with convulsion and coma," (Dorland's,

1974).

Endocarditis is "inflammation of the lining membrane of the heart

and the connective tissue bed on which it lies." (Dorland's, 1974).

Heroin (diacetylmorphine) is "a white, bitterish, crystalline

powder . . . formerly used as an analygesic and narcotic. Because it

is highly addictive, the importation of heroin and its salts in the

"nited States as well as its use in medicine is illegal." (Dorland's,

1974).

Lactose is "a constituent of milk (called milk sugar). It is not

colerated in many persons." (Dorland's, 1974).

Mongolism (Mongol, is "a member of one of the chief ethnological

divisions of Asiatic peoples"). Mongolism is "Down's syndrome--so-

called because of facial characteristics typical of this condition."

(Dorland's, 1974).

Morphine is "the principal and most active alkaloid (one of a large

group of substances found in plants) of opium . . . used as a narcotic

analygesic." (Dorland's, 1974).

Narcotic is "pertaining to or producing narcosis (a reversable

condition characterized by stupor and insensibility." (Dorland's, 1974).

Nasal Septem is "a dividing wall or partition separating the two

nasal cavities in the midplane, composed of cartilaginous, membranous

and bony parts." (Dorland's, 1974).

Nepenthe is "pertaining to or inducing peace and forgetfulness."

(Dorland's, 1974).

Opium is "an air-dried milky exudate obtained by incising the

12

unripe capsules of poppies. The unripe capsules yield a white latex

which when dried is known as crude opium." (Dorland's, 1974).

Phenylketonuria (PKU) is "an inborn error of metabolism." (Dor­

land's, 1974).

Post Partum is "occurring after childbirth or after delivery, with

reference to the mother." (Dorland's, 1974).

Post Partum Psychosis is "a psychotic episode, usually schizo­

phrenic in nature, occurring during the post partum period, which may

be precipitated by organic and/or toxic factors." (Dorland's, 1974).

Psychosis is "a general term for any-major mental disorder of

organic and/or emotional origin, characterized by derangement of the

personality and loss of contact with reality, often with delusions or

hallucinations." (Dorland's, 1974).

Pulmonary is "pertaining to the lungs." (Dorland's, 1974).

Staphylococcal Pneumonia is "caused by infection with staphyloccus,

many strains of which are antibiotic resistant; has a strong tendency

to extend beyond the original site of infection?** (Dorland's, 1974).

S taphylococcus is "a spiral bacterium occurring predominantly in

irregular masses of cells that are a common cause of pus forming

infections." (Dorland's, 1974),

Strabismus is "a squinting deviation of the eye which the patient

cannot overcome." (Dorland's, 1974).

Talc is "a hydrous silicate (salt), sometimes containing small

portions of aluminum silicate used as dusting powder." (Dorland's, 1974).

Tetanus is "an infectious disease in which muscle spasm and hyper-

ref lexia result in 'lock jaw1, generalized muscle spasm, arching of the back and seizures." (Dorland's, 1974).

13

Tetany is "a syndrome manifested by sharp flexion of the wrist and

ankle joints, muscle twitchings, cramps and convulsions," (Dorland's,

1974).

Toxemia is "a general intoxication sometimes due to absorption of

bacterial products formed at a local source of infection." (Dorland's,

1974).

Toxemia of Pregnancy is "a group of pathologic conditions occurring

in pregnant women, characterized by preeclampsia and fully developed

eclampsia, associated with edema (presence of abnormally large amounts

of fluid in the intercellular tissue spaces of the body.") (Dorland's,

1974).

Vasculature is "pertaining to blood vessels." (Dorland's, 1974).

Plan of Study

The purpose in this study was to compare the development of infants

born to narcotic addicted women to infants born to nonnarcotic addicted

women and discover family dynamics of addicted women in the study.

In addition, a purpose in this study was to document whether

changes in infant behavioral characteristics were evident, after pre-

and post-tests of mother-infant pairs who participated in an interven­

tion program which emphasized educational activities and involved

medical and cognitive approaches. A further purpose was to examine the

feasibility of a subsequent study. Instructional materials were

developed and utilized in a home-based intervention program directed

toward strengthening quality of mothering, or helping mothers develop

caregiving skills to their* infants. The subjects in this study were

ten newborn infants who were born in The Ohio State University Hospitals

14and Grant Hospital, Columbus, Ohio. Mothers of those infants were also

included in the study. Infant development was assessed with three

instruments. They included: The Amiel-Tison Neurological Maturity of

Newborn Infants, Brazelton Neonatal Behavioral Assessment Scale and

Bayley Mental and Motor Scales of Infant Development.

Maternal behavior was assessed with eleven instruments. They

included: Infant Care Inventory, Six Ainsworth Maternal Care

Scales, Caldwell et al. Inventory of Home Stimulation and a Parent

Counselor Home Visit Report adapted from Wright et al. (1970). Maternal

compliance with medical directions and appointments were assessed with

an instrument designed for that purpose. Case histories were obtained

for addicted mothers in this study.

Sources of variation among the groups were analyzed with several

statistical procedures.

Subsequent sections of this study will include a review of

related literature, research design, results, summary and implications.

CHAPTER XI

REVIEW OF LITERATURE

The focus in this chapter will be on features of narcotic addiction

as they relate to women during pregnancy and the post partum period

and as they relate to newborn infants. Also, a theory will be pre­

sented which might be useful when discussing infants of narcotic

addicted women. Views of Deutsch (1967), Cole and Bruner (1972),

Hess and Shipman (1965) and pavenstedt et al. (1967) will be presented

in support of theory.

Further, intervention programs and materials which have been

found to enhance infant attention will be described. In addition,

a description of some instruments which have been found useful for

infant and maternal assessment will be described.

Maternal Complications Associated with Narcotic Addiction

Several physicians have found that women who present histories of

narcotic addiction during pregnancy also manifest unfavorable symptoms

curing the period immediately following birth of their infants.

Among the symptoms reported are the presence of hepatitis (Stern,

1966; Schneck, 1958; Blinik, 1969) and syphillis (Stone, 1967 and Blinik,

1969). The complication of hepatitis is said to occur frequently in

addicts and is said to be related to common use of contaminated needle

and syringes. Blinik (1969) also found the presence of rheumatic fever,

15

16

anemia, epilepsy, diabetes and positive tests for syphillis among

narcotic addicted women.

In addition to the above complications Krause (1953) found women

who manifested withdrawal symptoms, retained placenta, hemorrhage and

also found one case of post partum psychosis. Few of the women had only

mild nervousness and insomnia, but most of them were reported to have

developed tremors and severe anxiety accompanied by episodes of crying.

Stern (1966) noted that chances of the presence of toxemia are

significantly greater among narcotic addicted women than among women

in the general population; placenta abnormalities are more frequent

and post partum hemorrhage is more likely to occur with narcotic

addicted women.

Stern (1966) studied obstetrical complications of sixty-six women

and found 15.1 percent of them to have experienced toxemia of pregnancy—

a figure which is reported to be highly significant when compared to

5.2 percent of all obstetric patients within the hospital in which the

study was made.

Other reported symptoms of narcotic addiction particularly with

heroin, are acute bacterial endocarditis, tetanus and malaria (Moser,

1974). He reported'that the medical problem is compounded by a total

lack of discrimination regarding what some people will pump into a

human vein. Virtually anything that is rumored to cause a "high" will

be reduced to an injectable sustrate. He reported that physicians may

encounter a person with a fever who may have an infected heart valve or

a patch of Staphylococcal pneumonia in relation to heroin addiction. He

further noted that physicians may anticipate a variety of non-infectuous

17

junk which is often injected into veins and may become lodged in the

lungs of a narcotic user.

Rosenow (1972) reported that heroin and other drugs are frequently

adulterated with quinine, lactose and talc as well as with baking soda.

In a pathetic effort to purify the mixture, it may be filtered through

cotton and as such, cotton fibres may become lodged in the pulmonary

vasculature. Other pulmonary complications may include abscesses of

the lungs.

Gottlieb and Boylen (1974) reported overdose coma and pneumonia.

Apton (1968) reported that a rare disease in heroin addicts is perfora­

tion of the nasal septum which is said to result from sniffing heroin.

Other complications of heroin use have been reported as infectuous

arthritis and neurologic disorders (Light and Dunham, 1974 and Richter

et al., 1973) .

A dramatic statement was made by Moser (1974) in which he noted

that perhaps the most serious disease related to heroin use is the state

of emotional despair that causes one to elect the personal suffering

that accompanies narcotic addition. It is a disease of society that has

always been with us in one form or another. Whenever men find the

tedium or frustrations of living to be beyond endurance, some seek

escape with Nepenthe. Moser (1974) presented a negative prognosis for

drug addiction when he noted that "there is no indication that we are

close to a cure for this chronic despondency of the human spirit."

The aforementioned physicians have agreed that narcotic addiction

during pregnancy and the post partum period presents symptoms within

the drug user that are potentially harmful and damaging.

18

Treatment Efforts for Narcotic Addiction

Several physicians (Dole and Nyswander 1965; Maslanslcy 1971;

Blinick et al. 1969; Knowles et al. 1971; Kleber 1971; Hoozerbeth 1971

and Wallach et al. 1969) have reported efforts directed toward

penetrating the drug problem in the United States. Those efforts

include the employment of Methadone as an interim measure for use by

addicts who are being treated for drug use. Two types of Methadone

programs have been described and both involve the intake of Methadone

orally with a mixture of fruit juice.

The first program is that of detoxification (Blinick 1967).

Treatment within that program is designed to avoid severe symptoms of

withdrawal. Depending on the size of the "habit" a dose of 20-40

miligrams of Methadone is given initially to the patient while in a

hospital and thereafter the dose is gradually decreased over a period

of seven to ten days. When the patient is free from drugs and no

longer seems to desire continued intake3 he is asked to remain in the

hospital for an additional two to four weeks for rehabilitation.

Blinick (1967) reported that the detoxification type of program has

been unsuccessful; the addict invariably returns to heroin use after

discharge from the hospital.

The second program described by Wallach et al. (1369) is referred

to as the Methadone Maintenance Program. That program is aimed at

voluntary rehabilitation of the 1 hard-core" addict through gradual

intake of Methadone. Patients are given gradually increasing doses of

Methadone to induce a state of tolerance. They are initially given

small doses of five to ten miligrams daily and are continued at this

level for one to two weeks. Then the dose is increased by increments

of five to ten miligrams at intervals of four to seven days, until an

average daily dose of 80 to 100 miligrams is reached. At that stage

the dose is held constant with the belief that such large doses

induce narcotic blockage, so that heroin becomes neither necessary

nor desirable and the addict, hopefully can return to a normal useful

life. Wallach et al. (1969) noted that under one Methadone Mainte­

nance Treatnent Program, with a comprehensive program of rehabili­

tation, patients have shown marked improvement, have lost their

craving for heroin and none have become readdicted to heroin.

Several physicians (Knowles et al. 1971; Kleber 1971; Hoozerbeth

1971; Maslansky 1971 and Dole et al. 1968) seem to favor Methadone

maintenance programs. They noted that a high rate of social produc­

tivity, as illustrated by stable employment and responsible behavior

on the part of persons who have participated in drug treatment programs,

has occurred with program participants.

Neonatal Complications Associated with Narcotic Addiction

Several unfavorable neonatal characteristics have been reported

for infants of narcotic addicted women. Prematurity of birth

(Gobrinik et al. 1956; Reddy et al. 1971), low birth weight among the

infants (Cobrinik et al. 1959; Slobody and Cobrinik 1959; Reddy et al.

1971), high mortality rates (Schneck 1958; Goodfriend et al.) and

periods of hospitalization ranging from four to twenty days are among

the conditions reported for infants of those women. Studies of

20

surviving permaturely born infants have found increased incidences

of mental and neurological deficit with increasing degrees of pre­

maturity among the infants who have been studied (Caputo and Mandell

1970). Deprived environmental circumstances were noted to adversely

affect the course of development of prematurely born infants (Drillien

1965). Scott (1972) noted that a positive correlation exists between

"hard narcotic users" and lower gestational ages in their infants,

and also noted that some cases of low birth weight among infants may

have been due to anorexic effects of narcotic use and poor nutrition

by the mother.

Further unfavorable outcomes of infants born to narcotic addicted

women have been found. Pierson et al. (1972) found "sudden infant

death syndrome" among three infants who were born to women who partici­

pated in Methadone Maintenance programs, but stated that the deaths

may or may not have been related to the use of Methadone.

Wilson et al. (1973) found behaviors of hyperactivity, brief atten­

tion span and temper tantrums among 64 percent of the infants whom they

studied. In a ten-year follow-up study of infants born to narcotic ad­

dicted women, Zelson et al. (1971) reported that maternal addiction seri­

ously affects the fetus and has a damaging effect on the newborn infant.

Schneck (1958) found infants who developed respiratory symptoms accom­

panied by the presence of mucous which necessitated use of oxygen therapy

for survival of the infants. He also found those infants to exhibit

irritability and restlessness, twitching and convulsive disorders

21

which he regarded as conditions that might lead one to suspect the

presence of tetany or central nervous system injury among the infants.

Lin-Fu (1969) noted that most infants born to narcotic addicted

women develop narcotic withdrawal symptoms and that approximately 83

to 91 percent of the infants are born addicted. There appears to be

general agreement among physicians regarding symptoms of withdrawal by

the infants: tremors, excessive and annoying high-pitched continuous

crying, generalized convulsions, vomiting, anorexia, weight loss, poor

feeding, diarrhea, tremulousness and excessive fist sucking (Kunstadter

et al. 1958; Cobrinik et al. 1956; Steg 1957; Schneck 1958; Stern

1966; Zelson 1971).

In addition, Schneck (1958) noted that as a result of restless­

ness and irritability, severe excoriations of the infants' heels,

noses and other points of contact with mattresses occurred. He also

found increased perspiration severe enough to produce a rash and

temperature elevations slightly over 100 degrees Fahrenheit. Perlmutter

(1967) found one child who had a positive Phenylketonuria and presence

of cataracts. Krause (1958) reported one case of Mongolism, one

infant with an umbilical hernia and severe strabismus. Ho also

reported that 25 percent of the infants in his study expired. He

expressed concern regarding abnormal tremor of the arms and legs

observed in infants, which was believed to herald the advent of

vomiting and an inability of the infant to nurse. He also found many

of the infants to experience difficulty with swallowing which he

noted may contribute to occurrance of respiratory crisis and cyanosis.

Perlmutter (1967) grouped infant symptoms into several major

22

categories: those referrable to the central nervous system such as

marked irritability, excessive crying, sleeplessness, tremors and

convulsions; those referrable to the gastro-intestinal system such

as vomiting, diarrhea and poor feeding; those referrable to the

respiratory system such as yawning, sneezing, fever, perspiration and

pallor. He further noted that it is uncommon for the infant to experi­

ence no clinical symptoms if the mother is taking drugs at the time of

delivery.

Physicians have attributed presence of withdrawal symptoms in the

infants to several factors. Goodfriend et al. (1956) and Statzer and

Wardell (1972) noted that the appearance or absence of withdrawal symp­

toms in the newborn infant seems to be related to the duration of addic­

tion by the mother, quantity of narcotics consumed by her and the time of

intake of her last dose.of narcotics immediately prior to the birth of her

infant. If the mother consumes large doses of narcotics until the very

end of her pregnancy there is the likelihood that the infant will be a

narcotic addict at birth. Zelson et al. (1973) attributed the degree

of illness of the infant to types of drugs consumed by the mother.

They noted that infants of addicted mothers who were using Methadone

alone or in combination with heroin appeared to exhibit a greater

degree of illness than those infants born to women who used heroin

alone. They found 12 percent of infants born to women who used

heroin required treatment as compared to 38 percent of infants born to

women who used Methadone and who were not treated. Those physicians

also found severity of withdrawal, frequency of withdrawal symptoms and

frequency of seizures to be greater in Methadone infants. Physicians

23

are nod in complete agreement regarding severity of withdrawal syndrome

in heroin and methadone addicted babies.

Blatman (1972) contended that Methadone babies are better off due

to the superior pre- and post-natal care available to mothers,

especially if they are treated in Methadone Maintenance Programs.

Harper et al. (1974) found that a low-dose Methadone program coupled

with intense psychological support appears to alleviate problems

associated with addiction in pregnancy, but fails to prevent withdrawal

in the newborn. Cohen et al. (1973) reported that acute symptoms may

occur more frequently, last longer and be more difficult to control in

infants born to women who receive methadone during pregnancy than

among those born to "street" heroin addicts. Rajegowda et al. (1972)

supported that notion. They noted that Methadone is not only

addictive to the fetus, but is associated with a higher incidence and

more prolonged duration of withdrawal symptoms that were observed

among newborn infants of heroin addicts. Weingold (1974) disagreed

with this position when he noted that there are no differences between

heroin effects and Methadone effects. Goodfriend et al. (1956) and

Steg (1957) noted that withdrawal symptoms do not occur in the newborn

infant unless the mother has been taking drugs consistently, with the

last dose being taken less than one week prior to birth of the infant.

Time of onset of symptoms may vary.

Onset of Infant Withdrawal Symptoms

Cobrinik et al. (1959) noted that the time of onset of clinical

findings in the infant depends on the duration of time the mother has

been consuming narcotics, type used and time of the last dose prior to

24

delivery. He noted that heroin is excreted more rapidly than morphine,

and therefore one would expect heroin to lead to earlier onset of

withdrawal symptoms. However, because of several factors no conclu­

sions may be drawn from present data. In one study Glass et al. (1971)

found that the onset of withdrawal symptoms in the newborn infant

ranged from immediately after birth to 52 hours of life of the infants.

Sussman (1973) found symptoms to occur within 12 hours after birth.

He found several of the mothers to be without symptoms, however their

infants developed symptoms later and that factor suggests that

narcotic addiction by mothers may not be readily detected. Naeye (1973)

studied seven women who were in prison or other institutions during

the last trimester of pregnancy and who exhibited no clinical features

of withdrawal. There are several problems associated with diagnosing

withdrawal symptoms.

Problems of Diagnosis

Diagnosis of addiction is said to present no problems when a

history of maternal addiction is available. However, history of

narcotic addiction may be difficult to obtain and document. Rosenthal

et al. (1964) noted that unless the patient admits to being an addict

or begins to show withdrawal symptoms before delivery or shortly

thereafter, there is no easy way to make a diagnosis of addiction.

Certain signs, however may be utilised in raising the index of suspicion

by medical personnel. The signs include: tatoo-like scars over veins

on women's hands, arms and legs; superficial infections over veins;

burned fingers and burned holes in clothing; and drowsiness and lethargy,

at times accompanied by a desire to scratch the body. Rosenthal et al.

25(1964) noted that a more reliable indicator of maternal addiction is

the development of withdrawal symptoms. If the addict is deprived

of drugs for about 12 hours or more, symptoms usually begin. Informa­

tion about the length and nature of the mother's addiction is usually

obtained from the mother with much difficulty and in most cases must

be considered unreliable, especially for several reasons.

The illegal nature of drug-taking activities hinders cooperative

effort between the addict and hospital personnel. In addition, drugs

available from criminal sources (primarily heroin) are subject to

widespread adultei'ation which makes assessment of actual doses nearly

impossible. Statzer and Wardell (1972) commented on strength of drugs.

The potency of pure heroin and quinine varies not only between

various areas of the country but within each city. Street heroin in

Detroit, for example, is said to contain approximately 10 percent

heroin, 10 percent quinine and 80 percent milk sugar. Lindsmith (1965)

noted that nearly all of the drugs used by American addicts are imported

into the United States from abroad. The drugs are said to arrive in

pure form and as they pass from the hands of one dealer to the next in

the long chain of distribution, which reaches from the importer to the

ultimate consumer, they are progressively diluted and broken up into

smaller and smaller units. Dilution at the lowest level is often in

excess of 90 percent and sometimes reaches 98 percent or more. Lind­

smith (1965) further noted that smuggled drugs may pass through as

many as 50 or 100 hands before reaching the consumer. Given these

cynamics it appears that the problem of drug addiction is immense.

Douglas (1971) reported that no commercial standards of quality

26

exist for heroin, and no user knows, and no physician can guess what

is the actual level of drugs consumed.

Prognosis of the Addicted Mother

Douglas (1971) noted that Che addicted individual even after

withdrawal, detoxification or rehabilitation remains at high risk in

that subsequent intake, even years later, sets up an immediate urge

for more drugs in order for the user to maintain function. It is this

fact which poses a vicious problem in the pregnant woman. She carries

a potentially addicted fetus and while detoxification of the newborn

infant seems to be initially a successfully detoxified baby, he is

still an infant with a problem who is released into a disturbed environ­

ment, in whom even a casual exposure to drugs later in life may induce

an addictive response.

Goodfriend et al. (1956) stressed the importance of an early

diagnosis in order that effective therapy may be instituted, without

delay. Stern (1966) noted that understanding the problems involved

with pregnant addicts, and knowledge concerning the behavior of the

drug addict is helpful.

Baer and Corrado (1974) noted that the most serious drug abuse

involves heroin and that some form of crisis intervention is necessary.

The investigators noted that long range solution to the problem must

regard the underlying causes and important influences which lead to

eventual drug use. Baer and Corrado (1974) attributed factors within

the family constellation during childhood, as contributing to drug

addiction during later life. They concluded that addicts more likely

led an unhappy childhood, experienced harsh physical punishment and

27

lacked parental concern in the areas of school, sexual conduct, friends

and career guidance. Stern (1966) noted that there are frequently no

goals, no plans, no responsibilities for the addict other than obtaining

enough money to pay for drugs. He further noted that the female addict

cares nothing about improving her condition as long as she can obtain

enough money to pay for drugs, and obtain enough of them to stave off

withdrawal symptoms and provide for her an occasional lift above the

condition in which she lives. Krause (1958) noted that although the

prognosis in heroin addiction is very poor he believes that with help

from Social Services and psychiatric assistance during the woman's post

partum convalescence some of the addicted women might be saved.

Care of Infants of Addicted Women

Several physicians expressed concern for infants of addicted women.

Lin-Fu (1969) noted that after an infant is cured of neonatal

narcotic addiction, his long-term care following discharge from the

hospital remains a problem. Because many addicts are not cured

permanently, and since some have been reported to deliberately induce

addiction in their children, early and perhaps permanent separation of

those infants from their mothers has been advocated by some physicians.

Cobrinik et al. (1956) and Slobody and Cobrinik (1959) advocated such

a procedure. Slobody and Cobrinik (1959) noted that since addiction

in a newborn is not based on conscious appetite with attendant

psychologic and sociologic problems, the infant can be cured permanently

of his addiction. However, if he is returned to his home, constant

follow-up is necessary to ensure him against environmental exposure to

addicts. He further noted that such a task is almost impossible since

28even their own mothers have been sometimes regarded as sources of

children's addiction at later dates. He concluded that if the

environment cannot be properly controlled, and he believes that it

rarely can, removing such an infant from his environment may be the

only hope for a permanent cure and a useful life.

Lin-Fu (1969) noted that such an action may not be desirable,

practical or possible in many situations. She proposed that careful

follow-up by health workers appears to represent an alternative, but

in many cases the unstable nature of the family setting precludes any

long-term supervision.

Schneck (1958) reported that since some babies are placed for

adoption one may wonder whether the infants are a good adoptive risk.

He posed the issue whether the mother's emotional instability, which

led her to resort to narcotics, foreshadows the neuro-hereditary

pattern of her offspring, or whether the infant's ultimate emotional

development is related to the environment. Resolution of these

crucial issues seems to pose problems that need solution as concern

continues to grow for the development of infants who are born to

narcotic-addicted women.

Prognosis of Infants of Narcotic Addicted Women

Blinick (1969) noted that the future of infants born to narcotic

addicted women, especially those infants of low birth weight, is

difficult to determine. Infants who are born with marked growth

retardation may have very different physical stamina and different

developmental capacities.

29

Developmental Outcome of Infants Born to Narcotic Addicted Women

Several investigators have devoted effort directed toward des­

cribing the course of development of some infants who were born to

narcotic addicted women. Some of those studies have described behavior

of those infants during the early neonatal period only, while a limited

number of investigators have followed some infants through the first

year of life. The findings from some of those studies have revealed

that infants of narcotic addicted women differ from infants of non­

narcotic addicted women on several behavioral dimensions. In some

instances those differences have been found with the use of the

Brazelton Neonatal Behavioral Assessment Scale (1973).

Soule et al, (1974) used the Brazelton Scale instrument for examin­

ing 19 babies of women who had used Methadone. They were from several

races, with black predominating, while some babies appeared to be of

mixed racial backgrounds. The babies were compared with 41 babies who

were born at a military hospital, of white parents who represented

military personnel of all ranks. Infants of the narcotic addicted women

were found to be restive and in a neurologically irritable condition.

They cried more often, were more tremulous and manifested less motor

maturity than the comparison group of infants and responded more poorly

to visual stimuli.

The investigators noted that economic disparities between the two

groups precluded the study of methadone babies as an isolated clinical

problem of drug addiction.

Lessen-Firestone et al. (1974) also used the Brazelton (1973)

Scale and compared 22 infants of narcotic addicted women with 22 infants

30of non-narcotic addicted women. Results of the study are reported in

terms of clusters of items from the Brazelton Scale. The clusters

are: 1) an excitability cluster which contains items that describe

the infant's level of arousal, 2) a passive motor cluster, composed

of involuntary and reflexive motor responses, 3) an active motor

cluster which deals with the infant's self-initiated motor movements,

and A-) a cognitive sensory cluster which contains two types of items:

those that measure response decrement to visual and auditory stimuli

habituation item), and those that measure orientation to animate

and inanimate stimuli, and an alertness scale. The infants were

nested at two age periods (24 and 48 hours).

Relatively little change in behavior of the infants was found

ever the 24 hour period, however, some change was found with respect

to excitability of the infants and their responses to a cloth placed

ever their faces. There was also a reduction in tremulousness at

the 48 hour period. Several group effects were found.

With respect to the excitability cluster, addicted infants

responded irritably to more stimuli and their behavior states changed

nore often. The infants were more likely to be drowsy or active

awake and fussy than nonaddicted infants. Addicted and nonaddicted

infants did not differ in the peak of arousal often elicited by the

stimuli that are used with the Brazelton Scale.

There were differences in startles and tremulousness from the

passive motor cluster in favor of the nonaddicted infants. Both groups

exhibited appropriate degrees of muscle tone and did not differ

significantly.

31

Few differences were found for items in the active motor cluster.

However, addicted infants tended to manifest less mature motor

behavior; they were more jerky in their movements and less cuddly

than nonaddicted infants.

Differences in the cognitive-sensory cluster appeared with only

one habituation item. Addicted infants required more trials to habituate

to light than their controls. With respect to the orientation and

alertness portions of the cognitive-sensory cluster, the rate of missing

was significantly higher for addicted than nonaddicted infants.

Addicted infants were less often in alert states and were less available

to interaction with the examiner than nonaddicted infants.

Conclusions drawn from this study seem important with respect

to mother-infant interaction. Lessen-Firestone et al. (1974) concluded

that congenital addiction affects behavior of the infant; the infant's

behavior may have implication on the early development of maternal-

infant affectional bonds, and it is likely that addicted infants

differ most from nonaddicted infants with respect to effects on the

caregiver. The addicted infant is likely to elicit more caregiving

responses, yet he is less likely to mold and cuddle when held, and is

likely to tax the caregiver's adaptability to providing care for him.

Wilson et al. (1973) observed the course of development of 30

infants of heroin addicts in the setting of a Maternity and Infant Care

High Risk Clinic. Of that number 16 remained in the study for less

than a year while 14 were observed for one year or longer. Withdrawal

symptoms persisted with 82 percent of the infants for three to six

months. Behavioral disturbances of hyperactivity, brief attention span

32and temper tantrums predominated. Associated with those disturbances

was growth impairment; several of the infants had growth indexes below

the tenth percentile at one or two years.

After subsidence of withdrawal symptoms the infants demonstrated

age-appropriate behaviors except where hyperactivity and short atten­

tion span interferred with adaptive performance.

During the course of developmental testing at 12 to 18 months

activity level of the children was decidedly abnormal. Although the

children completed age-specific tasks with swift precision, suggesting

normal potential, they lacked the persistence necessary to complete

the majority of tasks. One infant completed all required tasks, but

responded with constant motor activity which included climbing on

and creeping under the examination table.

Between one and two years, the emergence of impaired attention

span and hyperactivity were observed in half of the infants who were

enrolled in the clinic. Conclusion drawn was that the high incidence

of such problems in infants who previously experienced withdrawal

symptoms suggest that these findings may have a relationship to

intrauterin drug exposure.

The investigators expressed concern regarding the outcomes of

children of maternal drug addicts and suggested longitudinal study of

a larger group to confirm findings of the study.

Studies of infants born to narcotic addicted women have contained

information which suggests that many of those infants differ from

infants born to nonaddicted women along several dimensions. Theoretical

notions regarding functioning of some families will be presented.

33Theoretical Views of Family Functioning

Several writers have described the narcotic addicted population

on admission to hospitals for treatment (Knowles 1971; Lessen-Firestone

et al. 1974) and have found a group to emerge as being Negro with an

average age of 21 years or less who possessed less than high school

education, with no special vocational training and who emerged from

impoverished backgrounds with no employment. With such a profile

theoretical formulations may be viewed with the notion that certain

characteristics of disadvantaged persons may also be prevalent within

a population of narcotic addicted mothers of new born infants. The

populations described as disadvantaged relate to several ethnic groups

c£ persons (Deutsch 1967; Cole and Bruner 1972; Hess and Shipman 1965

and Pavenstedt et al. 1967).

Deutsch (1967) described the interaction of social and develop­

mental factors and their impact on intellectual growth of the child.

He noted that many children who come from socially impoverished homes

tend to exhibit several problems. His thesis is that lower-class

children enter school situations so poorly prepared to produce that

vrhich the school demands, that initial failures are almost inevitable

and that school experiences become negatively reinforced. He further

noted that children from underprivileged environments tend to come to

school with a qualitatively different preparation for the demands of

the learning process and behavioral requirements of the academic setting

than the preparation of middle-class children. Deutsch (1967) described

several characteristics of homes of disadvantaged children.

Deutsch found that in a disadvantaged child's home there is a limited

number of objects especially of books, toys, puzzles, pencils and

scribbling paper. He noted that presence of and use of such items would

increase the child's functioning with the tools that will confront him

when he arrives at school. Vicually the urban home of the disadvantaged

child was said to offer the child a minimal range of stimuli. Sparsity

of objects and lack of diversity of home artifacts which are available

and meaningful to the child in addition to the unavailability of

individualized training, provides the child few opportunities to

manipulate and organize the visual properties of his environment.

Those would Include figure ground relationships and spatial organiza­

tion of the visual field. Sparsity of objects to manipulate is said

to hamper development of functions in the tactile area. Children from

disadvantaged homes are said to lack perception of different shapes,

colors and sizes which middle class children have in the form of blocks

that are purchased for the children and also in the form of a variety

of cooking utensils which might be available to the child as playthings.

Homes of children from disadvantaged backgrounds are reported as

being void of verbally enriched interaction, but are regarded as noisy

homes which are for.the most part void of meaningful stimuli for the

child.

Deutsch (1967) believed that due to noise level within some homes

of disadvantaged persons the child under-develops the ability to wall

himself away from his surroundings and fails to develop the ability to

distinguish between relevant and irrelevant sounds and to screen out

the irrelevant. Further notions of poverty have been described.

Cole and Bruner (1972) proposed a notion that rests on the

35

assumption that a community of poverty is reflected in various forms

and deficits. The child of poverty is assumed to lack parental

attention on the basis that some homes are characterized by absence of

a father model, while the mother is said to be away at work or is less

involved in rearing her children than she would be according to middle

class standards. There is said to exist deficits in interaction and

less goal seeking behavior from the parents (Hess and Shipman 1965).

Pavenstadt et al. (1967) described families who were regarded as

disadvantaged and with "multiple problems." The families were noted

co be chronically on and off public relief, if not steady clients on

one or another public assistance program. The families were noted to

show minimal ability to plan ahead, while living largely in an un­

comfortable present, with backgrounds of shifting denigrated past.

Cther characteristics of the families were minimal capability of

:oanaging their own affairs or of utilizing those facilities that

society has to offer to the greatest advantage.

Pavenstedt et al. (1967) further noted that families with multiple

problems are those who have never been able to or have never been

allowed to develop a consistent sense of self or identity, and who

have developed inconsistent identities. Caution is presented from

the study that children from such families will no doubt develop a

pattern of relying on public assistance for their survival unless the

vicious circle of the living patterns in which they are reared is some­

how broken. Further theoretical efforts may be viewed in terms of

interventive involvement within the homes of infants or children.

Intervention Programs

The idea that providing intervention programs containing

stimulating activities would enhance the development of young children

from disadvantaged environments, was begun more than 30 years ago.

Skeels and Dye (1939) sought to determine effects on mental growth of

a radical shift in institutional environment of children who had been

regarded as mentally retarded. Thirteen children with ages ranging

between 7.1 and 35.9 months and IQ scores ranging from 35 to 89 com­

prised the experimental group. All were from homes of low social,

economic and occupational levels. The children were transferred from

the Iowa Soldiers' Orphans' Home to the Iowa Institution for Feeble­

minded Children and were placed in wards with older girls. Special

attention, play materials, language stimulation and outdoor play were

provided for the children. Each child had available to him one person

with whom he identified and who was especially interested in him.

The study was continued for two years. At the end of that period the

results were that an average gain of 27.5 IQ points was made, with

each child in the experimental group making a gain. Several conclu­

sions from that study are available.

A change from mental retardation to normal intelligence in children

of preschool age is possible in the absence of organic involvement, by

providing a more adequate psychological prescription; conversely,

children of normal intelligence may become mentally retarded under a

continued adverse influence of a relatively nonstimulating environment.

Further, an intimate and close relationship between the child and an

interested adult seems to be a factor of importance in the mental

37development of young children. Approximately twenty-five years after

the Skeels and Dye (1939) study, other intervention programs emerged

on the American scene.

Karnes et al. (1970) described a program in which mothers in

disadvantaged families were provided, during weekly sessions, an

educational program to use at home for stimulating cognitive develop­

ment of their children. Twenty mothers (including two grandmothers

who were responsible for care of their grandchildren), with infants

between the ages 12 and 24 months participated in the training

program, and fifteen of those mothers completed the program. They

were provided with transportation to a central meeting place and were

paid $1.50 an hour for attendance in order to pay for baby-sitting

services. The mothers met in two groups of ten persons each for

seven months during the first year, with weekly meetings being devoted

to child and mother-centered activities. Staff members made monthly

visits within the homes of the participants to help the mothers

establish a positive relationship with the baby and to reinforce

teaching strategies discussed at the meetings. During the second

year the program was conducted for eight months using the same format

as the previous year. The children were evaluated at the end of the

training program with the Stanford-Binet Intelligence Scale and the

Illinois Test of Psycholinguistic Abilities. On both measures the

children in the experimental group scored significantly higher than

those in the comparison group.

Wright et al. (1970) described a home visit program that pro­

vided cognitive, nutritional and health information to mothers in

38

disadvantaged homes, during pregnancy and until the infants reached

18 months of age. Initial weekly home visits were made in order to

aid expectant mothers in understanding their own nutritional needs

and to prepare for the arrival of their infants. During the last

weeks prior to the infants' birth the expectant mothers were shown

sensory experiences and vocalizing games in preparation for play with

the infants. From birth to six months of age the mothers were supplied

with information which dealt with emotional, cognitive and medical

needs of the baby. When the infants were between six and eighteen

months of age inexpensive educational toys were made by the mother and

project staff during some home visits and left with the mother for use

with the infant. The children were enrolled in nursery school which

was a part of the program.

Visits at that time were scheduled aroung the children's attendance

in school. Library books were taken into the homes on a weekly basis

and exchanged for those that were left during the previous week.

Several types of information were obtained from this home based

intervention program.

Mothers' reactions to staff personnel and to the instructions

were noted. Also noted were whether other persons were present within

the homes during the sessions, extent of interruptions that occurred

during visits and whether books and other educational materials were

present within the homes.

The findings were that initially five of the mothers seemed merely

to tolerate the staff, but changes in their attitudes in a positive

direction were observed as the program continued. The majority of

39

mothers were found to perform the activities with the children when

asked to do so. Due to the presence of as many as seven other child­

ren in some homes, specific activities were planned for older children

for the purpose of reducing the extent of interruptions during the

training sessions. Several families had books and other educational

materials within the homes; others had none initially but obtained

them as the program progressed.

Williams and Scarr (1971) provided early educational intervention

to a group of low birth weight children whose risks of both neurologi­

cal and social impairment were regarded as being high. Thirty children

of four age groups "birth to one year, one to two years, two to three

years, three to four years" were chosen for the study. Ten children

within each of the four age groups were assigned to each of three

groups. The three and four year old children were assigned to the

primary experimental group on the basis of their residential proximity

to the university at which the study was performed. Others were

randomly assigned to the second experimental and control groups.

Intervention efforts were different for the three groups of children.

Children in the primary experimental group received both educa­

tional toys and tutoring on a regular basis. Children in the second

experimental group received toys but no tutoring, while those in

control group received neither. Children were tutored for four months

by university students except the infants who were less than one year

old. Instead, the tutors talked with the mothers concerning the impor­

tance of stimulation and suggested play activities for the children.

Also the mothers were encouraged to bring the infants out of their

40

usually dark bedrooms and place them into lighted and partially decorated

living areas; to place the infants on firm surfaces such as floors in

order to aid locomotion; to provide materials for the infants to look at

and to listen to. Mothers were also encouraged to talk with their

infants. Older children were provided with an assortment of toys.

Several findings emerged from the study.

Motor task performance was not influenced by treatment in either

group for any of the children. Motor performance was found, however to

be strongly related to neurological status of the particular child. The

neurologically intact children who received tutoring earned scores, after

intervention, which were equivalent to those of other lower class, full-

term children. The strength of treatment was influenced by neurological

impairment. Children with no neurological damage and who received tutor­

ing and toys showed greater gains in verbal performance than the children

of the other groups. One interesting finding was that intervention with

provision of toys alone had no treatment effect on the children. Gains

seem to be related to instructional use of the toys as well as provision

of them.

Studies of Infant Attention

An intervention program for infants may include the use of several

types of stimuli. Many human newborns have exhibited the capacity to

various forms of stimuli. Evidence of such capacity has come from a va­

riety of studies of infant attention. Those studies indicate that infant

attention appears to be a function of presenting stimuli affecting various

sensory modalities. Significant studies have included at least four

types of stimuli used to elicit infant responsivity.

41

Studies of Attention to Auditory Stimuli

Wertheimer (1961) studied responses to auditory stimulus on a

single neonate. He reported that his newborn daughter at age ten

minutes turned her eyes in the direction of a soft click made near

the infant’s ear. He replicated the study with another newborn infant.

At three minutes after birth a series of trials was begun with the

use of a click in systematic order, with a toy "cricket" near either

of the infant's ears. Two observers independently recorded whether

the infant exhibited eye movements.

As soon as the first click was sounded the neonate who had been

crying with eyes closed, opened them and oriented in the direction of

the sound. After* 52 trials at eight trials per minute the

infant ceased responding. Movement was observed during 22

of the trials, 18 were in the direction of the sound and four

were in a direction opposite the sound. On the basis of information

from the two studies Wortheimer (1961) concluded that within ten

minutes after birth, rudimentary directional response is possible with

a human neonate.

Birns (1965) applied two auditory stimuli to 30 babies during

the first four to five days of life. In consideration of a soft tune

and a loud tune he wanted to know whether there are individual differ­

ences in the neonate's intensity of responses to several stimuli. He

found that neonates could be differentiated within the first 15

days of life in terms of constancy of their responsivity to external

stimuli. Types of infant responses included toe or finger flicker,

gross movement of extremities— flexion or extension, startle and crying.

42He found that some neonates consistently responded vigorously to all

stimuli; others responded moderately. Babies who responded vigorously

to one stimuli usually responded vigorously to all stimuli with

consistency. There appears to be general agreement among writers

regarding types of overt responses of infants when presented auditory

stimuli.

Field (1967) studied infants between the ages birth to 26 days

and found responses to include movements of the facial area, movements

of the arms, legs and feet, as well as cessation of movements and

changes in infant state. Daugherty and Cohen (1961) found similar

responses among infants who were between the ages four and 28 weeks,

lisenberg et al. (1964) found movements of the whole body, various

forms of arousal, such as increase in activity level on sudden onset of

r.ew activity and quiet orienting such as a significant decrease in

activity or complete cessation of on-going activity. Various forms

cf stimuli were used to elicit responses from the infants. Rattles,

china cups with metal spoons, human voice, xylophones (Daugherty and

Cohen 1961), soft and loud tones (Birns 1965), crumpling of fresh

sheets of onion skin paper, the striking together of wooden sticks,

root of a small plastic whistle and the beat of a drum (Eisenberg

at al. 1964), are among the stimuli used. In addition to responsivity

to auditory stimuli, infants have been found to respond to varying

types of visual stimuli.

Studies of Attention to Visual Stimuli

Darwin (1877) is said to have demonstrated interest in visual

attention of infants as he noted his infant son first began to visually

43

track a candle and other moving objects at the age of eight days. Since

Darwin's observations other studies have appeared. Recently, studies

by Berlyne (1958) and Fantz (1958) have been reported as having served

as a beginning of many other studies to appear in the literature.

Berlyne (1958) used four series of patterns constructed on

rectangular cards, with three different designs in each series. One

series contained black, gray and white rectangles; the other series

contained figures constructed of equal areas of black and white,

among which was a checkerboard design. One design consisted of black

and white dots randomly distributed on the background. Each pattern

had a one-half inch margin on each side. He presented the designs

to the infants and found that the black and white dots, together

with the checkerboard pattern were more likely to attract first

visual fixation by the infants.

Fantz (1958) sought to determine which pattern, among four pairs,

infants would prefer as measured by total fixation time on the pattern.

One pair of patterns consisted of a circle and a square equated in

area; another consisted of two identical triangles, while a third

consisted of a five-inch checkerboard that was paired on half the time

with a square of the same size and paired the remaining time with a

smaller square. The fourth pair of patterns consisted of a five-inch

square with alternating red and gray horizontal stripes and another

pattern that Fantz (1958) referred to as a "Bull's Eye." That pattern

consisted of a five-inch square on which was placed alternating circles

of gray and red with decreasing circumferences from the outer edges to

the central portion of the square.

44

While the infants were placed in supine position each pair of

patterned objects was presented to the infants for thirty seconds

twice in succession during weekly test sessions until ten records on

each infant were obtained. Several findings emerged from that study.

The pair of triangles and the cross and circle pair failed to

elicit consistent visual preferences among the infants. Two patterns

that presented variations in type and degree of patterns produced

significant results. Nineteen of the 22 infants fixated the checker­

board more than the square and 20 infants showed higher time scores

for the "Bull's Eye." On the basis of their results Fantz (1958)

concluded that visual patterns were discriminated by the infants in

his study during the first six months of life as evidenced by differ­

ences in fixation time.

Hershenson (1964) studied visual fixation in the human infant and

used,for a portion of his study, patterns that he classified as having

three levels of complexity. Least complex stimuli were constructed by

dividing stimulum area into quadrants and blackening in the first and

third quadrants. The intermediate stimulus was constructed by dividing

the stimulus area into 16 equal squares of checkerboard design,

while the most complex design was a checkerboard divided into 144

equal squares of one-half inch. He found that the least complex

pattern was significantly preferred over the most complex designs.

Mirando (1970) verified and extended the studies of Fantz (1958)

and Hershenson (1964). However, llirando studied prematurely born

infants and found that prematurely born infants showed preference for

patterned over plain stimuli. He concluded that infant preference was

45

so strong and consistent that such finding is potentially useful for

establishing presence or absence of pattern vision in newborn infants

and for revealing abnormalities in neural structures or function.

Salapatek (1968) utilized black and white solid and outline

circles and triangles of various sizes for eliciting visual fixation

and presented his figures on stimulus panels of 21 inches in diameter,

with the centers of all figures coinciding with the center of the panel.

He found that circles and triangles of any size that are centrally

placed in the infant's visual field attracted his gaze. He also

found that more time was spent looking at larger than at smaller

figures, while explaining that such a finding may be due to larger

figures occupying more of the infant's visual field. This study

verifies the Hershenson study in which infants fixated for longer

periods of time on figures of larger dimensions than of smaller.

Korner et al. (1971) utilized a different approach to the study

of infant visual attention than did Fantz (1958), Berlyne (1958),

Hershenson (1964), Mirando (1970) and Salapatek (1968). Korner et al.

(1971) investigated infant exploration within the context of maternal

care of the infant. She found that a high level of alertness was

evoked in the infants by holding the infant in an upright position to

the caregiver's shoulder. Such an intervention was said to involve

several simultaneous stimuli--contact, vestibular stimulation and

upright positioning. The finding was that in three out of four

trials, the process of holding the infant at the shoulder predictably

evoked alert scanning of the visual surroundings of a crying infant.

The conclusion was that vestibular stimulation has a powerful effect

46on evoking visual alertness. Also when a mother attempts to soothe

her infant by picking him up she will inadvertently provide him with

visual experiences which he could not receive were he not picked up

for soothing. Further, at least during the neonatal period, vestibular

stimulation is likely to be an important vehicle for stimulation of

certain types of developmental acquisitions. Assuming that visual

exploration is one of the most important pathways at the neonate's

disposal for early learning and for becoming acquainted with the

environment, vestibular stimulation and the upright position of the

infants attendant with maternal care, appear to be highly effective

vehicles for providing such opportunities.

Studies of Attention to Stimuli That Move

Studies have revealed that many human newborn infants have the

capacity to fixate on specific targets when presented within the

visual field. Other studies have shown that infants not only fixate

visually, in addition they are able to follow stimuli that are moved

across the visual field.

Carpenter (1974) studied visual following skills of infants who

were between two and seven weeks old. She was interested in determining

the effect of stimulus movement on the visual behavior of infants,

and in observing changes in visual responses to stimulus movement

over the early weeks of life. The infants were placed in a room

directly in front of a door on which blinking lights were mounted on

a white and black "bull's eye" pattern. The door was opened for

stimulus presentation parallel to the infant's face. Stimuli consisted

of three types of faces--tlie infant's mother's face and one of each,

47

a Caucasian and Negroid manakin head. The faces were presented in

stationary position and also while moving across the horizontal

plane of the infant's vision. Visual behavior was recorded in terms

of seconds. Four findings were in evidence from this study.

All faces received more visual regard from the infants when

moving than when stationary; infant attention increased with age for

both moving and stationary stimuli; manakin faces attracted more

attention than the mothers' faces. The conclusions drawn from this study

is that by at least two weeks of age stimulus movement is associated

with high fixation scores of infants.

Dayton et al. (1964) studied visual following behavior of 45

newborn infants whose ages ranged between eight hours and ten days.

To obtain results the investigators placed the infants on a bed-like

structure and suspended a semi-cylindrical plexiglass canopy, 30

inches in diameter over the infant's head. The target, which consisted

of a series of black dots four inches in diameter, and placed four

feet apart on a flat white surface was propelled by a motor over the

canopy in a left to right direction.

Fifteen of the infants fell asleep during the testing, 13 followed

less than two consecutive dots, while 17 of the infants were found to

demonstrate visual following of the stimuli for two or more presenta­

tions. The infants were noted to have located a moving target in the

visual field and follow the target as it moved across the arched

canopy. During the process of visual pursuit each eye moved simultane­

ously in the direction of the target. Some infants were found to pursue

two consecutive dots, then showed random movements as when no target was

presented and then again fixated on the target.

48Studies of Infant Responses to Tactile Experiences

Frank (1957) placed great significance on tactile experiences in

the newborn infant as a means of communication and as involvement in

interpersonal relations, extending from the period during gestation.

His notion is that infants need to be cuddled and patted. Such needs

are said to derive partially from uterine life, during which the fetus

is said to continually receive rhythmic impact of the maternal heart

beat. At birth the infant is said to emerge from a rhythmically

pulsating environment into a world where he has to learn to orient

himself to several modes of communication. The infant is said to

possess a repertory of processes that permit recognition of signals

and certain responses to those signals. He responds to the signals

given by the nipple and the tactile contacts during the nursing

process. His responses represent a message to the mother and she in

turn relieves his pain of hunger as she responds by lactation. She

further responds when she speaks or sings to him and he learns to

recognize his mother's voice as a partial substitute for her touch.

Frank (1957) noted that the child's later reception of verbal messages

is predicated to a great extent on his prior tactile experiences.

Tactile experiences, according to Frank (1957) are of such

importance that denial of them may compromise the infant's future

learning and capacity for more mature tactile communication. The

infant's communication with himself is said to provide a base on which

other experiences are built.

The infant is said to begin communication with himself by feeling

his own body, by exploring its shape and textures and as such he

49establishes his body image. Later such cues as focusing his eyes on

his hands and feet help him develop a visual image that may supplement

his tactile experiences. Frank (1957) talked about involvement of

tactile experiences in interpersonal relations. He noted:

Through the earliest bodily contacts and other tactile experiences, the baby communicates in a reciprocal way, mother to baby, and baby to mother, one evoking from the other what will in turn evoke his or her response in a tactile dialect. These experiences establish the individual's early pattern of intimacy and affection.. . . The baby develops confidence in the world, trust in people, through these early tactile relations which establish the meaning of the world for him and also his expectations and feelings toward that world. Thus, how the baby is treated, what tactual experiences he has while being bathed, clothed, tucked in bed, how he is mothered and handled by others govern his initial responses and by so much guides his subsequent learning and relationships.

Frank (1957) notes further:

If the baby is limited in his tactile experiences,denied much opportunity to send or receive tactilecommunications, he presumably must wait until his capacity for visual and auditory recognition have developed sufficiently to permit him to enter into communication with others. Such a child will not only have little of the primary tactile experiences upon which to develop his sign and symbolic communi­cation, but will be expected to rely on visual and auditory symbols and to accept their meanings, not as experientially learned, but as prescribed by others.

Frank contends that tactual stimulation is largely responsible for the

individual's eventual verbal abilities and all the baby's perceptions

and interactions with the world.

Support of the importance of tactile experiences comes from

Provence and Lipton (1962) who compared 75 infants reared in an

institution with infants reared in homes with their families. Upon

the finding that institutionalized infants failed to adapt to adult

50

holding, the investigators concluded that poverty of the infant being

lifted, touched, moved and cuddled began early in life to influence

the infant's adaptation to the environment.

Infant Assessment

In order to obtain data for this study there was a necessity to

select assessment procedures that would describe infant status along

several dimensions over several time periods from the first few days

of life until three or four months. Four instruments are described.

Apgar Procedure

The Apgar (1953) procedure is based on five types of infant

behaviors: heart rate, respiratory effort, muscle tone, reflex irrita­

bility and color, initially judged by physicians 60 seconds after

delivery of the infant. Each of those behaviors is assigned a rating

of 0, 1 or 2. A total score of 10 is said to be optimal and a score

of 3 or below represents an infant who is in poor physical condition

(Drage and Berendes 1966).

Neurological Evaluation

According to Amiel-Tison (1968) constant modification of muscle

tone and reflexes are affected by maturation of cerebral processes

during the last three months of fetal life. Procedures have been

devised for assessing neurological maturity of infants. A team of

French physicians (Andre-Thomas, Chesni and Saint Anne Dargassies, 1960)

described a procedure for neurological assessment of infants which

includes observations of spontaneous activity of the infant, elicitation

of reflex capacities and estimation of the extent to which latent

51

reaction might be present. Amiel-Tison (1968) described a neurological

examination procedure that is said to be based on the principles applied

by the French team (See Appendix I). The examination includes proce­

dures whereby the physician applies certain movements to the infant

during resting posture while the amplitude of passive movements of

joints is measured. In contrast, active tone is studied with the

infant in an active situation such as while being held in an upright

position. Gestational age of the infant is assessed from these manipu­

lations by the attending physician. Amiel-Tison (1968) presented no

evidence with respect to validity or reliability of the instrument.

Brazelton Neonatal Behavioral Assessment Scale

The Brazelton (1973) scale covers a wide range of infant behaviors.

It assesses some neurological items as well as social variables. The

behavioral items, of which are 27, are scored on a nine-point scale,

while the reflex items are scores on a three-point scale. A manual is

available for recording infant performance (See Appendix II). Four

pieces of materials are necessary for administration of the scale— a

standard flashlight, a bright colored ball, a rattle and a bell. The

examination requires between 20 and 30 minutes, and begins with a two-

minute observation prior to attempting to elicit infant responses. The

baby's initial state score is recorded at the end of the observation

period.

After the observation period stimuli which can be offered dis­

cretely (i.e., auditory and visual) are presented. While the infant

is still in the wrapped, quiet state (state 1, 2 or 3) the flashlight

is flashed across his eyes until he awakens or ceases responding for at

52

least three times. After the infant becomes quiet again the rattle and

bell are presented for a maximum of nine trials each. The infant is

then uncovered and any reactions to that change are recorded (such as

skin color, rapidity of buildup from quiet to agitated state).

While the infant is still in quiet state the sole of one foot

receives a light pin-prick (without penetrating the skin). Notation

is made with respect to how rapidly the infant is able to shut down

response to subsequent pricks. Assessment is also made of the infant's

state change as he moves to a wide-awake state. While the infant is

still dressed muscle tone as well as several reflexes are assessed,

including the Babinski, plantar and palmar grasp and ankle clonus.

The examiner is free to vary the order of administration of items

after the infant has reached an awake-alert state. While orientation

items appear near the end of the test, the examiner may try some of

those as soon as the infant is awake, alert and not crying (before

testing pull to sit or prone behavior). Constraints on test flexibility

necessitate that stimuli regarded as aversive (uncovering, undressing,

being pulled to sit, being placed in prone) be administered when the

infant is not in a crying state. Stimuli regarded as strongly aversive

are pin-prick, elicitation of the tonic neck reflex, elicitation of the

Moro reflex and elicitation of defensive reactions (cloth on face).

The infant may be undressed as he moves from sleep to wide-awake

alertness. Again, he should be observed for state change, lability of

skin color in response to disturbing maneuvers by the examiner. Tone

is assessed when the infant is handled and when he is first undressed.

Passive movements are evaluated at this point and followed by testing

53

for orientation response to visual and auditory stimuli (items 5 and

6 on the scale).

If he remains in the awake state he can be pulled to sit. The

next sequence includes assessment of standing, walking and placing

reflexes, incurvation, body tone while being held prone across the

examiner's hands. The infant is then picked up, held, and spun around

slowly for vestibular responses and nystagmus. Testing for orientation

responses to animate stimuli (items 7, 8 and 9 of the scale), is followed

by response to a cloth placed on his face, the tonic neck reflex and

Moro reflex. These manipulations are disturbing to the infant and

provide an opportunity for observing the infant's self-quieting be­

havior.

Measures such as hand-to-mouth facility, tremulousness, startle,

activity and alertness are continually assessed. A major emphasis on

the Brazelton Scale is to elicit the infant's best behavior. If the

infant has not responded to a particular stimulation, the examiner should

make every effort to verify that the infant is not capable of making a

better response, and should be aware of opportunities for repeating

tests later during the examination.

Another emphasis on the Brazelton scale is that the scale is to be

administered only during specified states. For example, infant response

to flashlight, bell, rattle and pin-prick are to be administered only

x̂ hile the infant is in states 1, 2 or 3. It is possible to utilize six

different states of the infant while administering the Brazelton Scale.

Brazelton (1973) noted that criteria for determining state are based on

personal experience as well as that of others. He defined them as

54

follows:

Sleep States

(1) Deep sleep with regular breathing, eyes closed, no spontaneous activity except atartles or jerky movements at regular intervals, no eye movements.

(2) Light sleep with eyes closed; rapid eye movements may be observed under closed lids; low activity level, with random movements and startles . . . respirations irregular, sucking movements occur on and off.

Awake States

(3) Drowsy or senii-dozing; eyes may be open or closed, eyelids fluttering; activity level variable, with mild startles from time to time. Movements are usually smooth.

(4) Alert with bright look; seems to focus attention on source of stimulation; impinging stimuli may breat through, but with some delay in response. Motor activity is at a minimum.

(5) Eyes open; considerable motor activity, with thrusting movements of the extremities; reactive to external stimulation; discrete reactions difficult to dis­tinguish because of general high activity level.

(6) Crying; characterized by intense crying which is difficult to break through with stimulation.

The Brazelton Neonatal Behavioral Assessment Scale (1973), de­

veloped by T. Berry Brazelton, M.D., has formerly existed as The

Cambridge Newborn Scales (Mimeographed). The Scale has been revised and

is now available from publishers. Self (1971) examined test-retest

reliability of the scale on the third and fourth days of life and again

at one month of age of infants. Mean Test-retest reliability for all

items within one agreement was 0.592; with agreement scores within

two points on the scale; it was 0.783 (Self, 1971).

The scale has been used to assess infants who have participated

in .several research projects. Scarr and Williams (1971) studied low

55

birth weight infants and examined the ability of the scale (the earlier

version) to predict developmental status of low birth infants at one

year of age. Assessment was performed at about seven days of age when

the infants' bodily temperature could be maintained outside an isolette

during the examining period, and again at four to six weeks of age,

when the infants were of nearly full-term weight. The findings were

twofold: 1) assessment at seven days of age was far more predictive

of later status than later assessments and 2) The Cambridge Newborn

Scales at one week proved much more useful than a standard neurological

examination given to prematurely born infants.

Freedman and Freedman (1969) used the Scale to study behavioral

differences between Chinese-American and European-Anerican newborn

infants. In that study the Caucasian infants showed greater lability

of state while Oriental infants tended to show more calmness in response

to aversive stimulation. Oriental infants also tended to show greater

habituation to presentation of a flashlight, and to show greater self-

quieting ability than Caucasian infants. In other areas (motor

development and social responsibity) the two groups were essentially

equal.

Brazelton (1975) noted that the scale may more accurately diagnose

"at risk" infants than the more commonly used neurological examination.

He reported that the standard neurological examination has been known

to produce 80 percent false alarm rate, while the Brazelton scale

produced only 24 percent false alarm.

Bayley Scales of Infant Development

The Bayley Scales of Infant Development are designed to provide

56

a basis for evaluating a child's developmental status in the first two

and one-half years of life (Bayley 1969). The Mental Scale is designed

to assess sensory-perceptual activities, discriminations and ability

to respond to these; the early acquisition of "object constancy" memory,

learning and problem solving ability; vocalizations and the beginnings

of verbal communications. Results from administration of the Mental

Scale are expressed as the Mental Development Index (MDI).

The Motor Scale is designed to provide a measure of the degree of

control of the body, coordination of the large muscles and finer

manipulatory skills of the hands and fingers. Results of the administra­

tion of the Motor Scale are expressed as the Psychomotor Development

Index (PDI).

The Bayley scales were standardized on the sample of 1,262 children

from various social-economic backgrounds and geographical regions. Norms

are available for infants between one month, 24 days and 30 months.

Tester-observer reliability on the 1958-1960 version of the Bayley

Mental and Motor Scales is 89.4 agreement with the Mental Scale and

93.4 with the Motor Scale (Werner and Bayley, 1966, reported by Bayley,

1969).

In an earlier study Bayley and Jones (1937) used the Bayley Scales

to assess relationship between Socioeconomic status and Mental develop­

ment. The finding was that for the first 18 months of life correlations

were close to zero or tended to be negative. After 18 months some

environmental factors develop positive correlations to mental scores.

By 72 months of age the total Socioeconomic scores showed .41. After

57the relationship became positive, the highest correlations were with

the mother's education (.58 and .59).

Cameron, Livson and Bayley (1967) extracted several clusters of

items from the California First Year Mental Scale (the scale from which

the Bayley Scales were derived). One of those clusters involved early

vocalization behavior of infants. The researchers found that vocaliza­

tion items appeared to be related to girls' intelligence (but not

boys') as measured at years six through twenty-six.

The age range covered by the Bayley Scales, the high reliability

and continued use of the scales contribute to the usefulness as an

instrument for assessing infant behavior.

Maternal Assessment

In recent years studies of human development have included

descriptions of environments within homes of infants and children in

order to try and determine to what extent human behavior may be

explained in terms of situations within homes which may be observed by

home visitors. Three instruments ai'e presented which have been used

in the context of studying the home environment.

The Caldwell et al. Inventory of Home Stimulation

Caldwell et al. (1966) developed an inventory of person-person and

person-object qualities which was regarded as collectively comprising

the infant's learning environment within the home, and to determine

which specific features of the environment were most likely to influence

development. It was noted that data from such an inventory might some­

how warn of developmental risk before age three years, and that such

58

data might help to pinpoint areas in which intervention may be needed.

A current inventory is now available which includes environment

characteristics believed to foster early development (See Appendix III),

The Inventory contains 45 items within six subscales: (1) Emotional

and Verbal Responsivity of the Mother, (2) Avoidance of Restriction of

Punishment, (3) Organization of Physical and Temporal Environment,

(4) Provision of Appropriate Play Materials, (5) Maternal Involvement

with the Child, and (6) Opportunities for Variety of Daily Stimulation.

Scoring of the Inventory is based on observation and partly on answers

to a semi-structured interview, administered in the home at a time

when the child is awake and when he may be observed in interaction

with the mother or primary caregiver.

Elardo et al. (1975) noted that extensive standardization data do

not exist for the inventory, however data from 176 families in Central

Arkansas indicate that the instrument is sensitive enough to register

a wide range of scores for families in identical social class designa­

tions, and there is a moderate degree of stability across the 18-month

life span. Internal consistency coefficients based on 176 cases range

from .44 for subscale six to .89 for subscale three. The internal

consistency coefficient for the total scale was .89.

Elardo, Bradley and Caldwell (1975) used the Inventory in a

study of 77 mothers and infants to determine which aspects of the early

home environment were associated with the infants' mental test performance

at age three years. Results were reported which were based on assess­

ment with the Inventory at three age periods (six months, twelve months

and twenty-four months).

59

High correlations were found between the Inventory at six months

of age and the infants' Stanford-Binet scores at age three years (.54).

High correlations were also found between the scores at 12 months

and 24 months, and the Binet scores at age three years.

The investigators concluded that the findings suggested that the

Inventory of Home Stimulation measures a complex of environmental

forces which may be prerequisites for later performance on cognitive

tasks. They further noted that the Inventory has the potential for use

in differential diagnosis of strengths and weaknesses which may be

present in an infant's environment and may assist those who are con­

cerned with designing intervention strategies.

Ainsworth Maternal Care Scales

Ainsworth studied attachment behavior to describe mother-infant

relationships. Ainsworth and Bell (1970) defined attachment as:

an affectional tie that one person or animal forms between himself and another specific one--a tie that binds them together in space and endures over time. The behavioral hallmark of attachment is seeking to gain and to maintain a certain degree of proximity to the object of attachment, which ranges from close physical contact under some cir­cumstances to interaction or communication across some distance under other circumstances.

Attachment behaviors are defined as behaviors which promote proximity

or contact. In the context of attachment behavior, Ainsworth (1973)

devised several scales for rating maternal behavior, during the first

quarter of the first year, of the infant's life.

Three of those scales are regarded as descriptions of subunits of

the general attitude of the mother towards baby, and her role. They

are: (1) Mother's Perception of Baby (Appendix IV), (2) Mother's

60Delight in Baby (Appendix V), (3) Mother's Acceptance of Baby (Appendix

VI). Three other scales are regarded as subunits of the mother's

availability and interaction. They are: (1) Mother's Availability to

Baby (Appendix VII), (2) Amount of Interaction Offered by Mother

(Appendix VIII), (3) Appropriateness of Mother's Initiation of Inter­

action (Appendix IX).

In order to administer the scales, ratings are performed on the

basis of narrative reports of observations of mothers and infants within

the home setting. Ainsworth (1973) reported inter-rater reliability

coefficients of .80-i-, based on ratings of two judges of each mother.

First quarter scales were reported to intercorrelate on the

average, quite highly. Ainsworth (1973) stated that high intercorre­

lations suggest that not all scales may be necessary to characterize

the first quarter of mother and infant interaction.

In the context of feeding behavior Ainsworth (1969) used four

scales which were utilized in this study of addicted infants: (1) Mother's

Perception of Baby, (2) Mother's Delight in Baby, (3) Mother's Acceptance

of Baby and (4) Appropriateness of Mother's Interaction with Baby. The

findings were that highest ratings earned by mothers were associated

with four types of feeding patterns: (1) a demand schedule (characterized

by consistent and demand feeding, (2) a flexible type of feeding

schedule (a schedule flexibly regulated by mothers who were highly

sensitive to infant signals), (3) a demand schedule (characterized by

overfeeding to gratify the infant) and (4) a scheduled type of feeding

(overfeeding to gratify the baby). Sensitivity to the baby's signals

and desire to gratify him were found to be prominent with mothers who

61

exhibited those feeding patterns. The mothers tended to respond promptly

and appropriately to the baby's crying and were found to be sensitive

to the baby's state and wishes.

Parent Counselor Home Visit Report

Wright et al. (1970) described a program which used home visitors

as disseminators of information designed to be helpful for growth and

development of the fetus and young children. Home visits were made to

families whose incomes were less than $5,000,00 a year, and were made

during the prenatal period and until the infants reached 18 months of

age. Emphasis was placed on nutritional needs of pregnancy and

lactation during the prenatal period. From birth of the infant until

six months emphasis was placed upon medical, emotional, cognitive and

material needs of the mother and the newborn infant.

Information from each home visit was summarized to provide several

types of data; (1) to note whether the parents or a caregiver were

available for the visit, (2) to determine how the caregiver reacted to

the home visitor on a personal level, (3) to note the extent of

activity and interruptions within the home during the visit, (4) to

note how the caregiver seemed to cope with the instructions provided

(whether or not she could or would do the exercises), (5) to note the

presence of educational materials within the home, and (6) to report

the way the caregiver seemed to feel about the program and her role in

it. Several findings emerged from the study.

During 90 percent of the visits, the mothers greeted the home

visitors warmly, were receptive and cooperative with their conversations.

62

Only five mothers continued to be disinterested. However, those mothers

changed their attitudes as the visitors made repeated visits.

Most of the visits were conducted at times when only the mother and

child were present. There were some cases in which from four to seven

adults were present in the room where the visit was taking place. One

visitor listed as many as seven children present in the room at the time

of the visit. Children would often interfere with the mother and baby,

and would attempt to take the materials which the home visitor had

brought for the mother's work with the infant. It was often necessary

for the home visitor to plan specific play activities for the other

children.

The majority of the mothers would perform the exercises when asked

to do so. Only three were reported as having refused. However, one

mother was reported to have refused consistently for the first seven

visits, but began to perform them when she discovered that her child

responded to the exercises which were provided.

Nineteen mothers appeared to have books or educational materials

available on the first visit and continued to have them. Ten mothers

had no books, but obtained them later. Eleven mothers had no educational

materials available when first visited, but obtained them later. The

majority of caregivers reported that the project was great for helping

them understand some of their infants' needs. Data with reference to

validity and reliability of the instrument were not available.

Infant Care Inventory

The Infant Care Inventory was developed by Hock (1972) for use

with mothers of infants who participated in a research study. In this

63

inventory mothers are asked to make a decision regarding whether they

or other persons could best perform various infant care skills. The

skills are the act of showing affection to the baby, preparing the

child and putting him to bed, calming the child, diapering the child,

understanding the baby's wants, teaching the baby games, feeding and

providing visual and verbal stimulation. Pairs of titles of persons

are presented for the mother to make her choice. The inventory is

presented in Appendix XI. Data which indicate validity and reliability

of the instrument were not available.

Two Factor Index of Social Position

The Two Factor Index of Social Position was said to have been

developed to meet the need for an objective, easily applicable procedure

to estimate the positions individuals occupy in the status structure

of American society (Hollingshead 1957). Its development was dependent

both upon detailed knowledge of the social structure and procedures

social scientists have used to delineate class position. It is premised

upon three assumptions: (1) the existence of a status structure in

the society; (2) positions in this structure are determined mainly by

a few commonly accepted symbolic characteristics; and (3) the char­

acteristics symbolic of status may be scaled and combined by the use

of statistical procedures so that a researcher may quickly, reliably

and meaningfully stratify the population under study.

Occupation and education are the two factors utilized to determine

social position. Occupation is presumed to reflect the skill and power

individuals possess as they perform the many maintenance functions in

the society. Education is believed to reflect not only knowledge, but

also cultural tastes. The combination of these factors by the use of

statistical techniques enables a researcher to determine within

approximate limits the social position an individual occupies in the

status structure of American society.

To determine the social position of an individual or of a household

two items are essential: (1) the precise occupational role the head

of the household performs in the economy; and (2) the amount of formal

education he has received. Each of these factors is then scaled

according to a definite system of scores. See Appendix XII for the

occupational and educational scales.

Summary

This review of literature included discussions of features of

narcotic addiction as experienced by some women during pregnancy and

during the post partum period, and also as experienced by their newborn

infants. Also, views of several writers were presented as they relate

to disadvantaged persons.

In addition, descriptions of intervention programs and of materials

used for enhancing infant attention were presented. Some instruments

which have been utilized for infant and maternal assessment were described.

CHAPTER III

METHOD

In this study the variates of neonatal assessment and criterion

variables of infant development, maternal care, program acceptance and

maternal compliance with medical appointments and suggestions were

compared between addicted and nonaddicted mothers and their infants,

in order to determine whether differences were found between the two

groups. Feasibility of a subsequent study was assessed.

Research Design

Subject Selection

The mothers and their infants who comprised this study were

selected upon referral from three sources. Three pregnant women were

referred from Vita Drug Treatment Center, two from The Ohio State

University Obstetric Clinic and another was referred by Pediatricians

while the mother was a maternity patient at The Ohio State University

Hospitals. Each of those women reported having consumed heroin while

pregnant, and two of them were participating in a Methadone Maintenance

Program during their pregnancy periods. Another woman who had a

"suspicious" drug history was referred by Pediatricians after the'

woman was discharged from the hospital and while her infant was

retained in the hospital due to his exhibiting withdrawal symptoms.

All seven of those women consented to participate in the study. Two

65

66

of them were lost to follow-up and five remained in the study. They

are referred to as narcotic addicted women.

Five other women who had no known history of drug addiction were

contacted for participation in the study while they were maternity

patients at The Ohio State University Hospitals. Those women are

referred in this study as nonaddicted women. Addicted women and their

infants were selected one at a time and matched with nonaddicted women

and their infants on the basis of Social Class Position (Hollingshead,

1957), ages of the mothers, gestational ages, birth weights and Apgar

scores (Apgar 1963) of the infants.

The mean age of addicted women was 24 years, four months. The

mean age of nonaddicted women was 24 years, eight months. The women

were from low socioeconomic position with eight of them receiving

public welfare support. The mean birth weight of addicted infants

was 3,115 grams. Mean birth weight of nonaddicted infants was 2,918

grams. (Table 1).

Case Histories of Addicted Women

Marital Status

Of the sample of five addicted women, three were single, one was

widowed, but shared living quarters frequently with her infant's

father. One woman was married and lived with her husband.

Residential Characteristics

All of the addicted women in this study resided in predominantly

Black neighborhoods. Their home environments differed with respect

to quality of housekeeping and extent of living space that appeared

TABLE I

CHARACTERISTICS OF T1IE SAMPLE

Study Group n = 5 Comparison Group n = 5

Family Data: Welfare Supported 4 4Father Present In Home 2

Ages of Mothers: X number of years 24 years, 4 months 24 years, 8 months

Social Class Position 61* 63*

Black Women 5 4White Women 0 1

Infant Data: Gestational Ages X 38.8 weeks 39 weeks

Birth Weight (grams) X 3115 2918

Apgar Scores (1 minute) 8.6 8.4

*Hollingshead (1957)

68

available. One woman resided in a two-floor house with her two

children and a sixteen year old brother, next door to the home of her

parents. Her furnishings were deteriorated but seemed moderately clean.

Case 2 shared one bedroom with her husband and infant, A drawer from

a chest and a wicker basket were used for the infant's sleeping

facilities. This family lived with the paternal grandmother and

appeared to have no furnishings of their own. However, the family

owned a new model Buick automobile.

Case 3 lived with her infant and two other children in the home of

her parents, together with a teen-aged brother. The interior of the

home was always dimly lighted with the draperies closed. Poor

housekeeping standards were evident; roaches were frequently seen

crawling on furniture and floors. Exterior of the home was badly

deteriorated; steps were difficult to climb due to broken sections.

Case 4 lived in..a second-floor apartment which was situated in a

commercial neighborhood. The halls of the building were unclean and

dimly lighted. Interior of the apartment was free from debris, but

the furniture was worn and soiled. The apartment was dimly lighted,

while on one occasion a table lamp containing a red bulb was lighted.

Draperies were always closed.

Case 5 lived in a "Halfway House" for women until her baby was

born. At that time, through aid from the local Welfare Department,

she was placed in a first floor portion of a duplex house. The interior

was clean and neatly furnished with worn furniture.

Number oC Children

The women varied with respect to their number of children. Cases

1, 2 and 4 each had two children; cases 3 and 5 had three.

Extent of Child Care Provided for Them by Others

Case 3 relied to a great extent upon her 14 year old daughter

for providing caregiving responsibilities to the infant as well as to

another child. Case 4 had a nine year old son who resided with his

maternal grandparents in another city. Case 5 reported one child who

lived in a foster home and another who lived with a maternal aunt.

In that respect, addicted women in this study were regarded as

"high risk" women with respect to their returning to illegal drug use.

Rothstein and Gould (1974) noted that addicted women who received

child care help from others may return to drug use, and may be regarded

as "high risk" women.

Educational Level

All addicted women in this study except one were high school

graduates, while two of them had received additional technical training.

Reason for Leaving School

Each mother noted that she left school due to graduation. The

one who did not graduate said she left because she became bored with

school.

Drug Experience

Case 1 denied her drug experience, but reported that her brother

had used drugs illegally. She was included in the study on the basis

70

of her infant's condition at birth. Physicians were hesitant and

deliberated for a long time and made the assumption that the infant's

condition could have been drug related, as they found no other basis

for his condition.

Case 2 used heroin until her pregnancy reached the third month.

She reported that she ceased use at that time in order to prevent

harming her unborn infant. She reported that use of heroin was related

to feelings of depression, associated with her husband's difficulty with

military involvement of an unexplained nature.

Case 3 reported heroin as the first drug used and as her present

drug and let it be known that she was persuaded to use drugs by a

friend. She reported use of heroin for five years and reported her

participating in a Methadone Maintenance program during the past two

years.

Case 4 used heroin as her first drug. She was participating in a

Methadone Maintenance program at the time of enrollment in the study.

She discontinued with Methadone while in the hospital, and failed to

return to the program. Subjective evidence seemed to support the

notion that she had returned to illegal use of drugs.

Case 5 reported the use of Codeine, and other drugs prior to

using heroin. She provided information which included her incarceration

for drug use and other unexplained offenses. At the time of enrollment

in the study she was on parole from a woman's reformatory for drug

use and other reasons.

Receptivity to Intervention Program

All women in this study were receptive to the intervention program

71

which was directed at contributing to enhancing quality of mothering or

helping -others become sensitive to infant needs and helping mothers

develop caro : ivin e skills. However, two of the women were inconsistent

in adhering to scheduled appointments. They eagerly scheduled appoint­

ments but failed to be available at designated times. All of the women

appeared to make some effort at attracting attention of their infants,

especially during presence of the visitor. A common occurrence among

the women was the act of presenting some form of auditory or visual

stimuli within the sensory range of the infants. Response of such

maneuvers was noted with the infants.

Data Collection

Intervention and Data Collection

Data collection for this study was interwoven with intervention

and was performed before delivery, during hospitalization following

delivery of infants and during home and Pediatric Clinic visits through­

out the first three months of the infants' lives. Data collection

occurred during three major time periods: during Phases I, II and III,

(See Table 2).

Phase I--3efore Delivery. The investigator visited pregnant women

at two drug treatment centers, described the study to them,

obtained demographic data and drug history from them with a »

Parent Counselor Interview form which was adapted from Bloom and

Sudderth (See Appendix XIII). Social position of the women was

obtained with the Hollingshead (1957) Two Factor Index of Social

Position, Appendix XII.

TABLE 2

SCHEDULE OF DATA COLLECTION

Phase I--Before Delivery

•Phase II--After Delivery

Maternity Room Contact

Phase III--Out Patient Status Throughout the First Three Months

DATA COLLECTION:

1. Hollingshead Two Factor Index of Social Posi­tion

2. Parent Inter­view Report

1. Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants

2. Developmental Examination (Brazelton Neonatal Assessment Scale)

Home and Clinic Visits

Ages of the Infants (Weeks)

Clinic Clinic ClinicH om e H om e H o m e and H om e and H om e and

H o m e H om e H om e

1 2 3 4 6 8 1 0 1 2

U M H ro i—* ro t—1 to t-> to l-» to r-1 1—1 f - W N H

CD OS p> i t w s£ os ■rr1 r->•-C S SS os a n os >fo rj H- H i-i r-c i-t CD i-t p n cd n O so so r 1*H-> 3 3 H* (a H* 3 H< Co H- •< H. Co i->- (5 3P j N OS 00 N 00 N 00 H- 00 t-- 00 H- CjO ^ Br 1-1 K3 CD 3 3* CD 3" CD ST O ST CD ~ o S O Sro i-* o r t i-1 r t t—1 r t fts r t s j r t 3 rr ro '< ot—* r+ •-* r t rr I-* i-1 r-* rji—• O r t CD o to O CD CD CD CD r-> rr

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t-“ 1—1 CD t-» t—‘ tD r-1ro • • rj • rj •i—1 < <» CD CD

3 3r t rrUs -p- H* US .p-Vw/ O O V '-Z

(P 5 s 3 3CD 2 H S

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so oq 3 00 CD H-t-> ST H 3 rj O• f t • rr < 3CD 1—13rrh>-O3

-otO

73

rhase II--After Delivery and Maternity Room Contact. Visitation

was performed with five women who comprised the comparison group

and two other women in the study group, after delivery of their

infants. The qame information was obtained from them as in Phase

Infant data were obtained at varying time periods.

Apgar (1953) scores of the infants were obtained by physicians

at age one minute and were recorded on the infants' records. The

Amiel-Tison (1963) Neurological Evaluation of the Maturity of

Newborn Infants was performed by the Pediatrician who supervised

the medical aspects of the study. In addition, the Brazelton

<1973) Neonatal Assessment Scale was administered by the investi­

gator when the infants reached approximately three days of age.

Hospital procedure was followed regarding clothing worn by staff

in the nursery areas.

Assessment of the infants was performed in a small room

adjoining the newborn nursery, after each infant was brought to

that area by staff nurses. Beginning the assessment with the

infant asleep as recommended by Brazelton (1973) often was not

possible. Administration of the scale provides for some flexi­

bility and when necessary such flexibility was utilized. When,

for example, an infant was crying, directions were followed for

consoling the infant. An observation period was engaged in prior

to attempting to comfort him, thus allowing an opportunity for him

to engage in self-quieting behavior. When the infant did not quiet

himself, comforting was provided according to directions in the

Manual which included presenting the Examiner's face to the infant,

74

prostint ini’; the face and voice to the infant, placing the Examiner's

hand on the infant's stomach, restraining one arm, then both arms,

holding him, holding and rocking and finally holding, rocking

and talking to the baby. Often comforting procedures were

accompanied by state changes, which were recorded with the use

of a mechanical counter. When infants were asleep the scale was

administered according to standard procedure. Upon completion

of assessment the infant was returned to the nursery by a hospital

nurse.

Phase IIT.--Out-Patient Status Throughout the First Three Months.

Medical surveillance was performed by the Pediatrician who

supervised the medical aspects of the study until there no

longer existed concern about infant withdrawal. At that time

and until the infants reached three months of age they were seen

according to regular schedules as needed by each infant, for

pediatric and routine well-baby care. In addition, the writer

made regular weekly visits to the homes of the infants until

they reached one month of age. After that time home visits

were made on a bi-weekly basis until the infants reached three

months of age.

When the infants reached one, two and three weeks of age the

Brazelton (1973) Scale was administered within the infants' home.

The same procedure for assessment was followed as when assess­

ments were performed in the hospital. A sofa, bassinett or infant

crib, when available, was utilized for handling the infant. A

booklet that contained suggestions for enjoying the infants was

75

l eft wiLli each mother at the end o I: Che first visit (Appendix

XIV). Maternal data were also gathered during the first home

visit (Table 2).

Each mother completed the Infant Care Inventory (Appendix

XI). The writer took notes in narrative form, of observations

of maternal care of the infant. On the basis of data derived

from those notes each mother was rated on six Ainsworth (1973)

scales. Ratings on those scales were recorded after having left

the infants' homes. Observations were also made concerning

social, emotional and cognitive support available within the

homes. Ratings of those indices were scored on the basis of the

Caldwell et al. (1966) Inventory of Home Stimulation (Appendix

III). Scores from Ainsworth (1973), Infant Care Inventory (1972)

and Caldwell et al. (1966) were used as pre-test data.

During the first three weeks of the infants' lives emphasis

was placed on talking to, playing with the infants and conversing

with the mothers regarding their concerns as well as needs of the

infants. When the infants reached four weeks of age materials

constructed from scraps of paper were used to enhance infant

attention (Figures 1-9). Use of those materials was continued

on a bi-weekly basis until the infants reached three months of

age. See Table 3 for schedule of intervention.

At the end of the three month period maternal behavior was

again derived from the Ainsworth, Caldwell et al. and other

instruments, and was used in the study as post-test data. Maternal

compliance with medical appointments and suggestions were rated on

Figure 1. Materials Used as Auditory Stimuli

77

Figure 2. Materials Used as Visual Stimuli

78

Figure 3. Materials Used as Visual Stimuli

Figure 4. Materials Used as Visual Stimuli

80

Figure 5. Materials Used as Visual Stimuli

81

Figure 6. Materials Used as Visual-movement Stimuli

82

Figure 7* Materials Used as Visual-movement Stimuli

83

Figure 8. Materials Used as Visual-movement Stimuli

84

Figure 9. Materials Used as Tactile Stimuli

SCHEDULE OF

INTERVENTION

fJJ■UrJw'4-te /-NM (A4-t a)o cu

e<D& (Ao 4Jw dcda> U-l

d4J Ha <4-1•w O4J CA•r4 0)W)<fiu•H<A•H>

CM

cc

vO

COI

85

1) Repeat use of Auditory Stimuli2) Repeat use of Visual Movement Stimuli3) Repeat use of Tactile Stimuli4) Repeat use of Stimuli with Marked

Contrast

1) Repeat use of Auditory Stimuli2) Repeat use of Visual Movement Stimuli3) Repeat use of Tactile Stimuli4) Present Visual Stimuli with Marked

Contrast

1) Repeat use of Auditory Stimuli2) Repeat use of Visual Movement Stimuli3) Present Tactile Stimuli

1) Repeat use of Auditory Stimuli

2) Present Visual Movement Stimuli

1) Utilize Auditory Stimuli with Infants

1) Play games with infants which require no materials

2) Talk with mothers regarding their concerns

86

a nonstandardized rating form designed for that purpose (Appendix

XV) which was based on the Ainsworth (1973) scoring criteria.

Case histories were prepared that described several charac­

teristics of the families in the study, which included marital

status, residential characteristics, number of children, extent

of child care provided for them by other persons, educational

level, reasons for leaving school, drug experience and receptivity

to the intervention program that was provided during the study.

In addition, acceptance of the intervention program and maternal

attitudes toward the program were recorded at the end of each

home visit on a report adapted from Wright et al. (1970). See

Appendix X.

Intervention Materials

Materials focused on stimulation of three sensory modalities and

included auditory, visual, visual-movement and tactile stimuli. See

Figures 1-9. Rationale for using the specific materials was based on

findings from several studies. Those researchers have reported that

the use of auditory stimuli (Wortheimer, 1961; Birns, 1965; Field,

1967; Daugherty & Cohen, 1961; Eisenberg et al., 1964), visual stimuli

(Darwin, 1877; Berlyne, 1958; Fantz, 1958; Hershenson, 1964; Mirando,

1970; Salapetek, 1968 and Korner et al., 1971), moving stimuli (Carpen­

ter, 1957; and Provence & Lipton, 1962) do enhance infant attention,

and evidence is found in various forms of infant responsivity, when

presented the stimulus materials. Activities for use with infants were

derived from Gordon and Lally (1968), Gordon (1970), Forrester et al.

(1971) and Cooper (1973).

87

A ssessment 1 ns trumonts

Thruu instruments were utilized to obtain infant data: 1) The

Amiol-Tison Neurological evaluation of the Maturity of Newborn

Infants (.1.968) was performed by the pediatrician while the infants

were in the hospital (See Appendix I). The neurological evaluation

was performed in order to assess gestational ages of the infants.

2) The brazelton Neonatal Behavioral Assessment Scale was administered

to the infants while they were in the hospital and again at ages one,

two and three weeks within the infants' homes according to directions

and scoring criteria which are found in Chapter II and in Appendix II.

3) The Bayley Scales of Infant Development provided a basis for

assessment of Mental and Motor Development and of Visual-Following

skills of the infants. Administration and scoring were performed

according to Bayley (1969).

Maternal data were assessed with eleven instruments; 1) Infant

Care Inventory, 2) six Scales from Ainsworth, 3) Caldwell et al.

Inventory of Home Stimulation, 4) A Parent Counselor Home Visit Report,

Wright et al,, 5) Mother's Compliance with Medical Appointments and

6) Mother's Compliance with Medical Suggestions. That instrument was

developed for use with this study. Scoring criteria were adapted from

Ainsworth (1973). No data with respect to validity and reliability

of the instrument were gathered.

Data Analysis

Data gathered for this study wore analyzed through the services

of the Department of Preventive Medicine and Veterinary Physiology

and Pharmacology. Dr. Jean Powers served as Consultant with

88

Ms. Linda Rolfes as Supervisor. Several scores were obtained Cor each

infant with the use of three instruments and for each mother with the

use of eleven instruments.

Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants

Differences between the groups of infants were obtained by means

of Fisher's Exact Probability Test. One hypothesis was tested

with the Amiel-Tison Neurological Evaluation of Maturity of Newborn

Infants.

Brazelton Neonatal Behavioral Assessment Scale

Three sources of data were derived from the Brazelton Scale:

1) infant response to 27 behavioral items, 2) response to the "Elicited

Responses" and 3) response to the state items. Sources of variation

of the items between groups and across four age periods were analyzed

through the use of Mixed Model Analyses of Variance. The statistical

technique Analysis of Variance allows for several items to be inves­

tigated at one time (Weiner, 1973). Through the Analysis of Variance

one hypothesis (Hypothesis 2) with three subparts was examined.

Bayley Scales of Infant Development

Infant response to each item on this test is recorded as Pass or

Fail. The total raw score representing a sum of the total items an

infant passes, is converted to a standard score, representing a

Mental Development Index for the Mental Scale, and a Psychomotor

Development Index for the Motor Scale. With use of that instrument

three hypotheses were tested. Sources of variations between the

89

groups of infants were analyzed with the use of a mixed model and a

one-way Analysis of Variance.

Maternal Assessment

Maternal assessment was performed with the Hock Inventory (1972),

Ainsworth Scales (1973), Caldwell et al. (1966) Inventory of Home

Stimulation, Parent Counselor Home Visit Report (Wright et al. 1970)

and with two forms which were designed by the investigator to assign

ratings for maternal compliance with medical appointments and sugges­

tions. Data received from maternal assessments were analyzed with

Mann Whitney U Tests.

Case studies were compiled for each mother who participated in

the study.

Statistical Methods Employed in this Study

Selection of statistical procedures to analyze data collected

was based on several considerations. In general, for the data yielded

by each assessment instrument, that procedure was chosen which

facilitated answering the maximum number of questions about the data

with maximum power. When an underlying normal distribution of the

data could bo assumed as with the 27 Brazelton behavioral items,

the State items, the Visual Following items from the Bayley Scales,

parametric procedures were used. For the Brazelton behavioral items

and state items, mixed model Analyses of Variance with repeated measures

and associated a posterori test such as Newman Keuls were employed.

For the Visual Following, a simple one-way Analysis of Variance was

the method of choice.

90

While the design of the investigation using the Brazelton "Elicited

Responses'' was identical to that of the behavioral and state items,

V.- no means couLd the data collected be considered normally distributed.

It was therefore, necessary to rely on a non-parametric technique.

Unfortunately, no nonparametric technique is said to exist that allows

one to explore three factors and their interactions. Wilcoxon Signed

Rank Test permitted evaluating differences between groups across the

"Elicited Responses" items at each of the four time periods, but could

not be used to test for differences among times or among the

"Elicited Responses" items.

Similarly, data collected with the Hock, Caldwell et al., the

Wright and the Compliance instruments fit into an experimental design

similar to that of the Bayley Visual Following. Once again, it was

not possible to treat the data as though it were normally distributed

and therefore, the Mann Whitney U Test was selected as the most power­

ful available technique, the required assumptions for which could all

be satisfied.

The experimental design implied by the data collected with

Ainsworth Scales imposed somewhat more of a problem. As in the case

of the "Elicited Responses" data it was not found to be possible to

analyze possible differences on one Scale. Mann Whitney U Tests for

differences between groups for each Scale were selected because of

their relative power to detect group differences within each Scale.

Choice of an analysis technique was difficult to analyze data

collected with the Amiel-Tison. Several techniques were considered

and discarded because of the data's failure to satisfy important

91

assumptions. Final Ly ten Fisher's F.xact Tests, one for eaeh item

were performed. It is unfortunate that the power of the Fisher

tosts to detect differences where real differences occur is relatively

1 .

Usefulness of Instruments Utilized in this Study

The Amiel-Tison Neurological Evaluation of the Maturity of New­

born Infants (1968) is a measure of infant postural indices. It is

useful by physicians for estimating gestational ages of infants.

Amiel-Tison (1968) reported no evidence of validity or reliability

of the instrument.

The Brazelton Neonatal Behavioral Assessment Scale (1973) provided

a means for assessing a comprehensive range of infant behaviors during

the neonatal period. Due to a narrow range of possible scores with

the "Elicited Responses" the possibility of determining significant

differences between groups of infants on the "Elicited Responses" is

1imited.Bayley Scales of Infant Development (1969) were useful for the

ai-e period which they are designed to assess. In addition to providing

a quantitative description of Mental and Motor development of infants,

the Scales are arranged such that an intra-test analysis may be made

and used for planning individual intervention strategies for infants.

The Ainsworth Scales (1973) failed to distinguish between changes

found in the groups of women in this study at pre- and post-test

periods. The lack of significant changes may have been related to

the hypotheses established in the study rather than to the instrument.

Significant differences may have been found had the research design

92

incorporated a provision for comparing prc-Lests of addicted women

with pre-tests of nonaddictcd women, as well as comparing post-test

scores of the two groups of women.

The Caldwell et al. (1966) Inventory of Home Stimulation was

useful for providing categories of indices which may be used by

home visitors. However, the Inventory comtains some items which are

of limited use with infants who are less than three months of age.

The Parent Counselor Home Visit Report was adapted from Wright

et al. (1970). The major divisions of the instrument contains unequal

numbers of subunits which create problems with respect to assigning

weights to each category of items in the instrument.

The Hollingshead Two Factor Index of Social Position (1957)

provides for ease in scoring. Some of the occupations listed in the

instrument may fail to appear with great frequency in the present

economy, especially those which pertain to rail road occupations.

The Parent Interview Report adapted from Bloom and Sudderth (1971)

appeared adequate for obtaining demographic data.

The instrument, Mother's Compliance with Medical Appointments and

Suggestions provided no data regarding validity and reliability of

the instrument.

The Infant Care Inventory (1972) failed to discriminate between

the groups of women in this study. Most women in the study earned

maximum scores with the instrument. It therefore appears that a

ceiling effect may have limited the power of the instrument to detect

group differences.

CHAPTER IV

RESULTS

The purpose in this study was to determine whether a difference

was found between development of infants born to narcotic addicted

women, and development of infants born to nonnarcotic addicted women.

Specifically, the purpose was twofold: 1) to test differences between

groups of infants and their mothers and 2) to describe the potential value of an intervention program for narcotic addicted and nonnarcotic

addicted women and their infants perliminary to a subsequent study.

In this study the variates of neurological maturity at birth of

the infants and neonatal status of the infants were examined in order

to determine whether significant differences were found between the two

groups of infants. With the use of several statistical procedures

thirteen criterion variables were examined to test the null hypotheses

of no difference between the groups.

Presentation of Results

Findings in this study with respect to each hypothesis are presented

sequentially.

No differences were found in neurological maturity (as assessed by

the Amiel-Tison Neurological Evaluation of the Maturity of Newborn

Infants), between infants of narcotic addicted women and infants of

nonnarcotic addicted women.93

94

Hypothesis 1: There is no difference between neurologicalmaturity at birth, of infants born to narcotic addicted women (as assess with the Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants) and neurological maturity at birth of infants born to nonnarcotic addicted women (as assessed by the Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants),

Alternative Hypothesis: Differences do exist between neuro­logical maturity at birth, of infants born to narcotic addicted women (as assessed with the Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants) and neurological maturity at birth of infants born to nonnarcotic addicted women (as assessed by the Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants. Infants of narcotic addicted women earn lower scores than infants of nonnarcotic addicted women.

Each item of the Amiel-Tison Neurological Evaluation was tested

for differences between groups by Fisher's Exact Probability Test.

The number of infants who received gestational age of 38 weeks or 40

weeks for the addicted group of infants was not significantly different

from the number of nonaddicted infants who received gestational ages

of 38 or 40 weeks, as shown in Table 4. Therefore, Hypothesis 1 was

accepted. There is no significant difference in neurological maturity

at birth of infants in this study who were born to addicted mothers

as compared to those born to nonaddicted mothers.

However, it cannot be concluded that narcotic addiction in the

mother has no effect on the neurological maturity and gestational ages

of the newborn infant. Since the physical condition (as assessed by

the Apgar) of the infants in the addicted group was matched to that of

nonaddicted infants by Apgar scores, birthweight and gestational ages,

the matching process may thus have obscured such differences if they

existed.

TABLE 4

ITEMS

SUMMARY OF DIFFERENCES BY FISHER EXACT PROBABILITY TEST IN GESTATIONAL AGES OF NEWBORN INFANTS OF ADDICTED AND NONADDICTED MOTHERS DETERMINED BY ITEMS OF T1IE AMIEL-TISON NEUROLOGICAL EVALUATION OF MATURITY OF NEWBORN INFANTS

ADDICTED INFANTS N

Gestational Ages 38 40

1 0 5 5

2 1 4 5

3 5 0 5

4 0 5 5

5 0 5 5

6 0 5 5

7 0 5 5

8 0 5 5

9 0 5 5

10 0 5 5

NONADDICTED INFANTS N SIGNIFICANCE

38 40

1 4 5 N.S.

1 4 5 N.S.

2 3 5 N.S.

0 5 5 N.S.

0 5 5 N.S.

0 5 5 N.S.

0 5 5 N.S.

1 4 5 N.S.

1 4 5 N.S.

1 4 5 N.S.

ME

AN

SC

ORES

9•o A d d i c t e d G r o u p

K o n - A d d i c i e d G r o u p8

7

6

5

4

3

2

1

01 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

I T E M N U M B E R S

Figure 10. Summary of Means of Addicted and Nonaddicted Infants with Twenty-Seven Brazelton Behavioral Items VOO'

96

Hypothesis 2a: There is no difference between performance withthe 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to narcotic addicted women and performance with the 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

Alternative Hypothesis: Differences do exist between performancewith 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to narcotic addicted women and performance with the 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks). Infants of narcotic addicted women exhibit less complex behavior with the 27 behavioral items.

Ages of the infants in this study are referenced with four

symbols: T^ refers to age three days; T2, Tg and T^ refer to agesone, two and three weeks respectively.

Inspection of Figure 10 reveals that responses averaged over ages

of the groups of infants were different for some items. When the

responses of the infants were examined by the 2 (Group) X 4 (Time)

X 27 (Item) mixed model Analysis of Variance with repeated measures,

several differences were found. In addition, significant main effects

of Group, Time and Item, significant Group X Item, and Time X Item

interactions were found as shown in Table 5. The null Hypothesis was

therefore rejected, and the Alternative Hypothesis was accepted. The

initial analysis was followed by 2 (Group) X 4 (Time) mixed model

Analysis of Variance for each of the 27 items. A summary of the

significance of effects of Group, Time and Group X Time for the 27

behavioral items appears in Table 6.As seen in Table 6, seven items had only significant Group Main

Effects, that is, the infants scores differed only with respect to

97

TABLE 5

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE FOR TWENTY-SEVENBRAZELTON BEHAVIORAL ITEMS

Source of Variation df MS F Significance

Group 1 161.08 10,78(1,8) P < .05

Subjects Within Groups 8 14.94 N.S.

Time 3 20.63 5-48(3,24) P<.01

Group X Time 3 2.50 0.66 N.S.

Time X Subjects Within Groups 24 3.77 N.S.

Item 26 43.11 9.02 P <.001

Group X Item 26 19.82 4.15 p < .001Item X Subjects Within Groups 208 4.78 N.S.

Time X Item 78 1.75 1.59 p <.01Group X Time X Item 78 0.87 .80 N.S.

Time X Item X Subjects Within Groups 624 1.10 N.S.

I

TABLE 6

SUMMARY OF THE SIGNIFICANCE OF EFFECTS FOR GROUP X TIME FOR THE TWENTY-SEVEN BEHAVIORAL ITEMS

ITEM GROUP TIME GROUP X TIME

1. Response Decrement to Light p < .05 N.S. N.S.2. Response Decrement to Rattle N.S. N.S. N.S.3.4.

Response Decrement to Bell Response Decrement to Pinprick

P <.01N.S. N.S. N.S.

5. Orientation Response— Inanimate Visual p <.01 p < .05 N.S.6. Orientation Response— Inanimate Auditory P<.01 N.S. N.S.7. Orientation— Animate Visual p <.001 N.S. N.S.8. Orientation— Animate Auditory P <.05 p <.05 N.S.9. Orientation— Animate Visual and Auditory P <.oi N.S. N.S.10. Alertness p <.05 P < .05 N.S.11. General Tonus N.S. N.S. N.S.12. Motor Maturity P <.05 p <.01 N.S.13. Pull-to-Sit N.S. P <.05 N.S.14. Cuddliness p <.05 p <.001 p <.0115. Defensive Movements N.S. P < *05 p <.0516. Consolability with Intervention N.S. N.S. N.S.17. Peak of Excitement N.S. N.S. N.S.18. Rapidity of Buildup N.S. N.S. N.S.19. Irritability N.S. N.S. N.S.20. Activity (Alert States) P <.05 N.S. N.S.21. Tremulousness (All States) N.S. N.S. N.S.22. Amount of Startle During Exam N.S. N.S. N.S.23. Lability of Skin Color N.S. N.S. M.S.24. Lability of States (All States) N.S. N.S. N.S.25. Self Quieting Activity p <„001 p <.001 N.S.26. Hand to Mouth Facility (All States) P <«05 N.S. N.S.27. Smiles (All States) N.S. N.S. N.S.

99

addiction status of their mothers; Item l--Response Decrement to

Li'cht, Item 3--Response Decrement to Bell, Item 6--0rientation

Response--Inanimate Auditory, Item 7--0rientation--Anj.mate Visual,

Iter. S--Orientation Animate, Visual and Auditory, Item 20--Activity

Level and Item 26--Hand to Mouth Facility. Means for those items are

found in Table 7.

TABLE 7

SUMMARY OF STATISTICALLY DIFFERENT GROUP MEANS FOR THE GROUP X TIME ANALYSIS OF VARIANCE ON ITEMS WHERE ONLY GROUP WAS SIGNIFICANT AS A MAIN EFFECT

Items AddictedGroup

NonaddictedGroup Significance

1 3.95 6.05 p < 0.05

3 3.75 5.55 p < 0.016 3.85 5.75 p < 0.017 2.60 5.00 P < 0.001

9 3.60 5.75 p < 0.0120 6.15 4.70 p < 0.05

26 ' 4.10 6.00 p<0.05

Addicted infants responded with less mature behavior with each of the

above items than nonaddicted infants. For example, Item 1 may be

interpreted: addicted infants continued to respond to presentation

of a flashlight over ten trials while nonaddicted infants demonstrated

dimunition of response within a range of five to seven trials. The

means of the two groups were significantly different and this suggests

100

chat infants of narcotic addicted women in this study were less

capable of terminating response to the presentation of a flashlight,

than -cere infants of nonnarcotic addicted women. An example of

creep differences is summarized for Item 1 (Response Decrement to

Light'* in Table 8. Table 8 shows that there were group differences among the infants.

TABLE 8SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON

ITEM 1— RESPONSE DECREMENT TO LIGHT

Source of Variation df MS F Significance

Group 1 44.10 9,97(1,8) pCO.Ol

I ima 3 0.47 °*59(3,24) N.S.

Group X Time 3 1.37 1,73 (3,24) N.S.

A similar interpretation is submitted for Item 3, which assesses

an infant's response decrement to the presentation of the sound of

a bell. Addicted infants demonstrated less mature ability than non­

addicted infants to shut down response to an auditory stimulus.

Items 6, 7 and 9--0rientation responses to inanimate auditory, animate visual and animate--visual and auditory, assess the extent to

which an infant alerts toward positive environmental events, such as

the human face, a ball and the sound of a rattle. Infants of addicted

women in this study oriented to animate and inanimate objects at lower

levels than infants of nonnarcotic addicted women.

101

With Item 20--Activitv, infants of narcotic addicted women

exhibited more activity during the examining periods and demonstrated

less hand to mouth activity (Item 26> than infants of nonnarcotic

addicted women. Summaries of Items 3, 6, 7, 9, 20, and 26 are found in Tables 21-26 (Appendix XVI). With each of those items addicted infants

performed with less mature behavior than nonaddicted infants. Item

20--Activity (Table 8) reveals a higher score for addicted infants than for nonaddicted infants. A high score with activity represents a

less mature type of behavior on the Brazelton Scale than a lower score.

This indicates that addicted infants were more active during the

examining period than nonaddicted infants. After stimulation, which

triggered activity of the infants, addicted infants exhibited much

activity which tended to perpetrate itself during the examining period.

Group and Time differences as Main Effects were found with

respect to five items: Item 5--Orientation Response--Inanimate Visual,

Item 8--0rientation--Animate, Auditory, Item 10--Alertness, Item 12—

Motor Maturity and Item 25--Self-Quieting Activity. With Item 5 for

example, (Orientation Response— Inanimate Visual), the group means

across all four age periods of the infants were: Addicted--2.5;

Nonaddicted--5.5. This means that as the examiner moved a bright red

ball across the infant's field of vision, addicted infants stilled,

brightened their eyes and made brief following, while nonaddicted

infants focused on and followed the stimulus horizontally for at least

a 30° arc, thus exhibiting more mature behavior than addicted infants.

An example of Group and Time differences is presented for Item 5

(Figure 11). As seen in Figure 11, both groups of infants performed better over time.

102

wUJa.Oum

Z<

o o A d d i c t e d G r o u p

Ar— A N o n - Add i c ted G r o u p8

6

4

2

OT4Tl

Ages of t h e I n f a n t s

^gure ll--Group Means of Brazelton Item 5, at Four Age Periods

As the ages of the infants increased, their scores tended to increase

also. Infant scores with Item 5 at T, (age three weeks) are signifi-4cantly different from scores at (age three days), and from scores

at I (age one week), p 0.05. Their means at each time period with

Item 5 were as follows:

Addicted Group 2.0 2.4 2.2 3.4Xor.adiicted Group 4.0 4.6 5.2 6.8

The absence of Group X Time interaction indicates that differences

between group means remained constant for all four time periods.

Infant performance with Items 8, 10, 12 and 25 showed that addicted infants oriented toward the sound of a human voice with less

complex behavior, they were less alert, exhibited less motor maturity

and were less able to quiet themselves than nonaddicted infants.

Means for Items 5, 8, 10, 12 and 25 are presented in Table 27(a),

103

Appendix XVII. Inspection of Table 27 (a) shows that significant

differences were found between the groups of infants with each of the

five items. Differences were in favor of nonaddicted infants. A

summary of significantly different Group and Time means is presented

in Table 27 (b), Appendix XVII. Pairs of means bracketed and flagged

with a single asterisk were found to be different at the significance

level, p 0.05, Those pairs of means bracketed and flazzed with a

double asterisk were found to be different at the significance level

p 0.01.With respect to Item 13 (Pull to Sit--a measure of the extent to

which the infant is able to right his head upon being pulled into a

sitting position), there were only time effects. The following means

at each time, across the two groups were found;

4.5 5.1 5.7 5.7

These means order themselves over time. T^ mean is the lowest; T^ is

next; T^ and T^ are alike numerically. Since T3 and T^ were alike, they were pooled for a collection of three means, rather than four,

upon which a Student's Newman Keuls test for all possible differences

was performed. Mean at T^ was found significantly different from means

at T3 and T^, (p 0.05). This indicates that changes occurred between

age three days and ages three and four weeks with both groups of infants.

At age three days when pulled to sitting position the infants1 shoulders and arm tone increased (Mean = 4.5); while in sitting position

they lifted their heads. Although they were unable to maintain a

104righting position, the infants made efforts to right the head. By

the time they reached age three weeks, they were able to bring their

head? to the midline of their bodies and maintain that position for one

or twc seconds (Mean - 5,7). No significant group differences were

found but both groups of infants made progressive gains with the Pull

to Sit item, as their ages increased.

Item 14 (Cuddliness) assesses the extent to which the infant

cuddles in the examiner's arms when held. Significant effects o f

Group. Time and the interaction of Group and Time were found. The

group means at each time follow:

Addicted Group

Nonaddicted Group

4.60

5.40

4.80

5.40

4.80

6.40

4.80

6.60

Inspection of Figure 12 shows that addicted infants remained relatively

constant in their cuddling and nestling behavior with the examiner,

while nonaddicted infants increased their level of cuddling behavior.

V)IUa0U)

Z<Uls

o— o A d d i c t e d G r o u p

a A N o n - A d d i c t e d G r o u p8

6

4

2

OU

Ages of t h e i n f a n t s

Figure 12--Group Means of Brazelton Item 14, at Four Age Periods

105

At T^, and tlie groups were different (p<0.05); at 1’2 there was no difference. Table 9 shows the means for each group at those times

where group differences were significant. In general, addicted infants

demonstrated less cuddling behavior than nonaddicted infants.

TABLE 9

SUMMARY OF GROUP MEANS FOR THOSE TIMES WHEN DIFFERENCES WERE SIGNIFICANT WITH BRAZELTON ITEM 14--CUDDLINESS

Ages Addicted Infants Nonaddicted Infants Significance

3 days (T^ 4.60 5.40 p < 0.05

2 weeks (T3) 4.80 6.40 p < 0.05

3 weeks (T,) 4 4.80 6.60 p < 0.05

With further respect to Item 14 (Cuddliness), at age three days

addicted infants were able to mold in the examiner's arms, but only

after a great deal of cuddling and nestling by the examiner. Nonaddicted

infants, on the other hand usually molded and relaxed when initially

held. They nestled the head in the elbow of the examiner; when placed

in vertical position at the shoulder they appeared to lean forward.

Little change was made over time in the cuddling behavior of addicted

infants.

Item 15 is a measure of the extent of defensive behavior exhibited

by the infant in removing a cloth held on the upper portion of his

face. Results of the Analysis of Variance shown in Table 10 indicate

106

that significant differences between infant groups with respect to

that behavior were not consistent over time.

TABLE 10

SUMMARY OF ANALYSIS OF VARIANCE FOR BRAZELTON ITEM 15--PULL TO SIT

Source of Variation df MS F Significance

Group 1 0.40 0,17(1,8) N.S.

Group X Time 3 2.83 3 91(3,24) p < 0.05

Figure 13 indicates that the direction of group differences is not

the same at T^ where the addicted group seems to be superior, as at T^

and T^, at. which the nonaddicted group is manifesting greater defensive

behavior. Although differences between groups are not significant at

any time, the cross-over of directions of difference probably accounts

for the significant Time interaction.

V)UJocOuVI

Z < uj2

o Ad d i e t e d G r o u p

Csr A N o n - A d d i c t e d G8

6

4

2

OT■ * o

Ages of the i n f a n t s

Figure 13--Group Means of Brazelton Item 15, at Four Age Periods

107

On the basis of findings of significant differences on behavioral

items in the Brazelton Scale (Table 6), Hypothesis 2a is thereforerejected, with consequent acceptance of the Alternative Hypothesis that

differences do exist between infants born to narcotic addicted women

and infants born to nonnarcotic addicted women.

Differences were found with respect to the infants' state which

was observed at each time period prior to administering the assessment

items. Within two minutes before the examination is begun with the

Brazelton Scale, an assessment of the infant's state is made by observing

his spontaneous behavior, respirations, eye movements, startles and

concurrent spontaneous events in the environment.

Hypothesis 2b: There is no difference between performancewith the Brazelton State items of infants born to narcotic addicted women and performance with the Brazelton State items of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

Alternative Hypothesis: Differences do exist betweenperformance with the Brazelton State items, of infantsborn to narcotic addicted women and performance with the Brazelton State items of infants born to nonnarcotic addicted women at four age periods (three days, one, two, and three weeks). Infants of narcotic addicted women demonstrate higher scores with State items than infants of nonnarcotic addicted women.

A 2 (Group) X 4 (Time) X 2 (State) mixed model Analysis of Variance

with repeated measures on Brazelton State scores was done, the results

of which appear in Table 11. Since the Group X Time X State interaction

was significant, this was followed by a 2 (Group) X 4 (Time) mixed

model Analysis with Repeated Measures for each state (Initial State and

Predominant states of the infants). Results of the analysis for

State 1, shown in Table 11a reveal that the groups of infants differed

at some point in time.

108

TABLE 11

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE FOR BRAZELTONINITIAL STATE AND PREDOMINANT STATE ITEMS

Source of Variation d£ MS F Significance

Group 1 5.00 2.82 (1,8) N.S.

Subjects Within Groups 8 1.78

Time 3 2.00 N.S.

Group X Time 3 4.60 3*91(3,24) p <*.05

Time X Subjects WithinGroups 3 1.18

State 1 140.45 158.25 (1,8) p <.001Group X State 1 2.45 2* 76 (1,8) N.S.

State X Subjects WithinState 1 0.89

Time X State 3 0.45 *58(3,24) N.S.

Group X Time X State 3 2.72 3*52(3,24) p <.05

Time X State X SubjectsWithin Group 3 0.77

109Table I la

SUMMARY OF RESULTS OF GROUP X TIME ANALYSIS OF VARIANCE FOR BRAZELTON INITIAL STATE ITEMS

Source of Variation df MS F Significance

Group 1 7.2250 4.45 N.S.

Subjects with Groups 8 1.6250

Time 3 2.0250 1.13 N.S.

Group X Time 3 6.8917 3.85 P < • 05

Time X Subjects with Grouos 24 1.7917

1 1 0

A significant Group X Time Interaction effect in the analysis

for State 1 (Initial State) necessitated testing for differences

between means of addicted infants at each time period in order to

determine the time period where significant differences occurred.

At (age three days) the mean initial state score for addicted

infants, 4.40, was significantly higher than the corresponding mean

of nonaddicted infants (1.40). This means that at age three days

addicted infants were exhibiting a higher level of arousal than non­

addicted infants, during the period of observation prior to beginning

the assessment with the Brazelton Scale. No significant effects were

demonstrated for State 2 (Predominant State).

Due to the finding of a significant difference at T^ (age three

days) between infants of narcotic addicted women and infants of

nonnarcotic addicted women, Hypothesis 2b was rejected. The Alternative

Hypothesis was accepted; differences do exist between the groups of

infants, with respect to their initial state at age three days.

No differences were found between infants of narcotic addicted

women and infants of nonnarcotic addicted women with respect to

"Elicited Responses" in the Brazelton Scale.

Hypothesis 2c:' There is no difference between performance with Brazelton "Elicited Responses" of infants born to narcotic addicted women and performance with Brazelton "Elicited Responses" of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

Alternative Hypothesis: Differences do exist between per­formance with Brazelton "Elicited Responses of infants born to narcotic addicted women and performance with Brazelton "Elicited Responses" of infants born to nonnarcotic addicted women. Scores of infants born to narcotic addicted women will reveal a lower magnitude than scores of infants born to nonnarcotic addicted women.

Ill

""lie iced Weaponsos” arc reflex behaviors which are elicited by the

examiner on various regions of the infant's bory. No statistical

:es: •..■as done because by visually comparing the number of babies in

each group responding with a value of two on the Brazelton "Elicited

Responses" items, it is clear that both groups of babies were reacting

in a similar manner for each of the twenty items at each of the four

time periods. Results which show the number of infants who earned

scores of two, are summarized in Table 12. Hence, Hypothesis 2c

failed to be rejected.

No significant differences were found between Mental Development

(as assessed with the Bayley Scales of Infant Development) of the two

croups of infants.

Hypothesis 3: There is no difference between MentalDevelopment (as assessed with the Bayley Scales of Infant Development) of infants born to narcotic addicted women and Mental Development (as assessed with the Bayley Scales of Infant Development) of infants born to nonnarcotic addicted women at two age periods (one month, 24 days and three months).

Alternative Hypothesis: Differences do exist betweenthe two groups of infants. Infants of narcotic addicted women obtain lower scores with Mental Development (as assessed with the Bayley Scales of Infant Development) than infants of nonnarcotic addicted women (as assessed with the Bayley Scales of Infant Development) at two age periods (one month, 24 days and three months).

When results of infant performance were analyzed through a 2 (Group) X

2 (Time) mixed model Analysis of Variance, no differences were found

between the two groups. Therefore, Hypothesis 3 failed to be rejected.

Differences were found, however, between scores at one month, 24 days

and at three months of age (Table 13).

TABLE 12

Nil MB UR OF INFANT’S IN EACH GROUP RECEIVING A SCORE OF TWO WITH BRAZE LTON "ELICITED RET IMiCKS" AT FOUR AGE PERIODS (THREE DAYS, Tx; ONE WEEK, T2; TWO WEEKS, T3; THREE WEEKS, T/,)

ANALYZED WITH WILCOXON SIGNED RANK TEST

TIME PERIOD AND GROUP 1 2 3 4 5 6ELICITED 7 8 9

RESPONSE 10 11

ITEMS12 13 14 15 16 17 18 19 20

Addicted Infants •5 5 5 4 4 5 5 4 5 4 5 5 2 4 5 5 1 1 2 2T1

Nonaddicted Infants Addicted Minus

5 3 5 5 4 4 5 4 4 5 5 5 1 5 5 5 2 2 2 2

NonaddictedT" = 21.5; N = 9

0 +2 0 -1 0 +1 0 0 +1 -1 0 0 +1 -1 0 0 -1 -] 0 0

Addicted Infants 5 5 5 5 5 5 5 4 4 4 4 5 2 5 4 4 2 2 3 3

T2Nonaddicted Infants Addicted Minus

5 3 5 5 4 5 5 3 3 4 4 5 2 4 5 5 3 2 •> 2

NonaddictedT“ = 15; N = 10

0 +2 0 0 +1 0 0 +1 +1 0 0 0 0 +1 -1 -] -1 0 + 1 +1

Addicted Infants 5 5 5 4 5 5 5 4 5 4 5 5 1 3 5 5 3 3 3 3

T3Nonaddicted Infants Addicted Minus

5 5 5 5 4 4 4 5 5 5 5 5 2 5 5 5 4 4 4 4

NonaddictedT+ = 18; N = 12, N.S

0•

0 0 -1 +1 +1 +1 -1 0 -1 0 0 -1 -2 0 0 -1 -1 -1 -1

Addicted Infants 5 5 5 5 5 5 5 4 5 4 4 4 1 4 5 5 /, 4 4 4

T4Nonaddicted Infants Addicted Minus

5 5 5 5 5 4 5 5 5 5 5 4 1 5 5 5 2 2 2 2

NonaddictedT" = 12, N = 9, N.S.

0 0 0 0 0 +1 0 -1 0 -1 -1 0 0 -1 0 0 +2 +2 +2 +2H-1-N

112

113

TABLE 13

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BAYLEY SCALES OF INFANT DEVELOPMENT— MENTAL SCALE

Source of Variation df MS F Significance

Group 1 378.45 1,03(1,8) N.S.

lime 1 432.45 16.20(i,a) p < 0.01Group X Time 1 14.45 0,54(1,8) N.S.

Fhe mean score across groups at one month, 24 days was 85.1, while the

mean score at age three months was 94.4 (p<0.0l), thus indicating

increased performance of 9.3 points over the two time periods with both

groups of infants.

Differences ware found between Visual Following skills of the two

groups of infants as assessed, with the Bayley Scales of Infant Develop­

ment .

Hypothesis 4: There is no difference between VisualFollowing skills (as assessed with the Bayley Scales of Infant Development) of infants born to narcotic addicted women, and Visual Following skills (as assessed with the Bayley Scales of Infant Development) of infants born to nonnarcotic addicted women at age three months.

Alternative Hypothesis; Differences do exist between infants of narcotic addicted women and infants of non­narcotic addicted women with respect to Visual Following skills (as assessed with the Bayley Scales of Infant Development) at age three months. Infants of narcotic addicted women earn lower scores than infants of nonnarcotic addicted women.

With the use of a one-way Analysis of Variance, differences were found

114between the two groups of infants (Table 14). Hypothesis 4 was,

therefore, rejected. The Alternative Hypothesis was accepted.

TAB If • 4

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE OF VISUAL FOLLOWING SKILLS WITH BAYLEY SCALES OF INFANT DEVELOPMENT

Source of Variation df MS F Significance

Group 1 10.00 5-88(l,8) P < °-05

The group means with Visual Following skills were as follows: Addicted

Group = 7.2; Nonaddicted Group = 9.2. Addicted infants visually

followed stimuli less often than nonaddicted infants.

No differences were found between the groups of infants with

respect to Psychomotor Development (as assessed with the Bayley Scales

of Infant Development).

Hypothesis 5: There is no difference between PsychomotorDevelopment (as assessed with the Bayley Scales of Infant Development), of infants born to narcotic addicted women and Psychomotor Development (as assessed with the Bayley Scales of Infant Development) of infants born to nonnarcotic addicted women at two age periods (one month, 24 days and three months).

Alternative Hypothesis: Differences do exist betweenPsychomotor Development (as assessed with the Bayley Scales of Infant Development) of infants born to narcotic addicted women and infants born to nonnarcotic addicted women (as assessed with the Bayley Scales of Infant Development). Infants of narcotic addicted women earn lower scores than infants of nonnarcotic addicted women.

When the scores of the infants were analyzed through a 2 (Group) X

115

2 (Time) mixed model Analysis of Variance, no differences were found

between the tvo groups of infants (Table 15). Hypothesis 5 failed to

be rejected. inspection of Table 15 reveals that significant differences

did occur between scores at age one month, 24 days and at age three

months of the infants. Both groups of infants demonstrated gains in

their scores ever the two time periods.

TABLE 15

SUMMARY 07 RESULTS OF ANALYSIS OF VARIANCE WITH BAYLEY SCALES 07 INFANT DEVELOPMENT— PSYCHOMOTOR DEVELOPMENT

Source of Variation df MS F Significance

Group 1 51.20 0 *38(1,8) N.S.

Time 1 1513.80 25'18(1,8) p < 0.01Group X Time 1 359.20 4-31(l,8) N.S.

No significant differences were found between narcotic addicted

women and nonnarcotic addicted women with respect to their feelings of

competency for providing caregiving skills to their infants.

Hypothesis 6; There is no difference between narcotic addicted women and nonnarcotic addicted women with respect to their feelings of competency for providing caregiving skills, as assessed with the Hock Infant Care Inventory.

Alternative Hypothesis: Differences do exist betweennarcotic addicted women and nonnarcotic addicted women with respect to their feelings of competency for providing caregiving skills to their infants.Narcotic addicted women exhibit less feelings of competency (as assessed with the Ilock Infant Care Inventory), than nonnarcotic addicted women.

116

When the scores of the groups of women were compared by means of the

Mann Whitney U Test, no differences were found (Table 16), Hypothesis

6 failed to be rejected,

No differences were found between addicted women and nonaddicted

women with respect to changes in characteristics of mothering between

pre- and post-test periods.

Hypothesis 7a: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to amount of change in characteristics of mothering, derived from pre- and post-tests (as assessed with Ains­worth Maternal Care Scales: Perception of Baby, Delightin Baby, Availability to Baby, Acceptance of Baby, Amount of Interaction with Baby and Appropriateness of Initiation of Interaction with Baby).

Alternative Hypothesis: Differences do exist betweenaddicted and nonaddicted women, with respect to changes in characteristics of mothering derived from pre- and post-tests (as assessed with Ainsworth Maternal Care Scales) Perception of Baby, Delight in Baby, Availability to Baby, Acceptance of Baby, Amount of Interaction with Baby and Appropriateness of Initiation of Interaction with Baby), Narcotic addicted women earn lower scores with Ainsworth Maternal Care Scales than nonnarcotic addicted women.

Scores were obtained from both groups of women with respect to the

six Ainsworth Scales at two time periods; 1) at pre-test period

(during the first home visit) and 2) at post-test period (during the final home visit). When scores which reflected changes between pre-

and post-test values were compared by means of Mann Whitney U Tests,

no differences were found (Table 17). Therefore Hypothesis 7a failed

to be rejected.

No differences were found between narcotic addicted women and

nonnarcotic addicted women with respect to amount of ahcnge in charac­

teristics of mothering assessed with the Caldwell et al. Inventory of Home Stimulation.

117

TABLE 16

DIFFERENCES BETWEEN SCORES OF ADDICTED AND NONADDICTED WOMEN WITH HOCK INFANT CARE INVENTORY ANALYZED WITH MANN WHITNEY U TEST

Groups Pre-Test Post-Test Differences Between Pre-and Post-Tests

Addicted Women 40 40 039 40 +139 40 +140 40 039 40 +1

Nonaddicted Women 34 39 4*540 38 -240 40 039 40 +140 40 0

U = 7 N.S.

1 1 8

TABLE 17

DIFFERENCES BETWEEN SCORES OF ADDICTED AND NONADDICTED WOMEN WITH AINSWORTH MATERNAL CARE SCALES ANALYZED WITH MANN WHITNEY U TESTS

Scale MA-1 Mother's Perception of Baby Scale MA-2 Mother's Delight in Baby

Addicted Women Nonaddicted Women Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D iff . Test Test D iff.

3 5 2 7 9 25 7 2 7 9 25 5 0 5 7 25 5 0 5 9 43 9 6 3 9 6

U = 12, cXl=1.00

Scale MA-3 Mother 's Acceptance of Baby

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D if f . Test Test D iff .

5 5 0 7 9 25 7 2 9 9 05 7 2 7 9 27 7 0 5 9 43 9 6 9 9 0

U = 8, ot. = .420N.S.

Scale MC-3 Amount of InteractionOffered by Mother

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test Diff. Test Test Diff.

1 1 0 9 9 03 5 2 9 9 05 7 2 7 7 05 5 0 5 9 41 9 8 9 9 0

U = 8, oC =.420 N.S.

Pre- Post- Pre- Post-Test Test D iff . Test Test D iff.

3 5 2 7 9 21 5 4 9 9 05 3 -2 7 9 27 7 0 5 9 41 9 8 9 9 0

U = 9 <x = .588

Scale MC-1 Mother's A va ilab ility toBaby

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D iff. Test Test D iff.

3 1 2 9 9 05 5 0 7 7 05 7 2 7 9 25 5 0 7 9 21 9 8 9 9 0

U = 9, OC = .588N.S.

Scale MC-4 Appropriateness of Mother'sIn it ia t io n of Interaction with Baby

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D iff. Test Teat D iff.

1 1 0 9 9 05 5 0 7 9 25 7 2 5 7 25 5 0 5 9 41 9 8 9 9 0

U = 10, C < = .69 N.S.

119

Hypothesis 7b; There is no difference between narcotic addicted women and nonnarcotic addicted women with respect to changes in characteristics of mothering assessed with the Inventory of Home Stimulation.

Alternative Hypothesis: Differences do exist betweennarcotic addicted women and nonnarcotic addicted women with respect to changes in characteristics of mothering assessed with the Inventory of Home Stimulation. Narcotic addicted women earn lower scores with respect to changes in characteristics of mothering (assessed with the Inventory of Home Stimulation), than nonnarcotic addicted women.

Scores were obtained from both groups of women with respect to the

Inventory of Home Stimulation at two time periods: 1) at pre-test

period (during the first home visit), and 2) at post-test period (during the final home visit). When scores which reflected changes between pre-

and post-test values were compared by means of Mann Whitney U Test, no

significant differences were found between the groups (Table 18).

Therefore, Hypothesis 7b failed to be rejected.

No differences were found between addicted and nonaddicted women

with respect to their acceptance of home training probided by a home

visitor.

Hypothesis 8: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to their acceptance of home training provided by a home visitor (as assessed with a Parent Interview Report--Wright et al.).

Alternative Hypothesis: Differences do exist betweennarcotic addicted women and nonnarcotic addicted women with respect to their acceptance of home training (assessed by a Parent Counselor Home Visit Report-- Wright et al.). Narcotic addicted women accept training by a home visitor less often than do non­narcotic addicted women.

When scores of the two groups of women were analyzed by means of

120TABLE 18

DIFFERENCES BETWEEN SCORES OF ADDICTED AND NONADDICTED WOMEN WITH CALDWELL ET AL., INVENTORY OF HOME STIMULATION ANALYZED WITH MANN WHITNEY U TEST

Category I--Emotional and Verbal Responsivlty

Addicted Women

Category I I —Avoidance of Restriction of Punishment

Nonaddicted Women Addicted Women Nonaddicted Women

Pre­rest

Post-Test D iff.

Pre-Test

Post-Test D iff.

Pre-Test

Post-Test D iff .

Pre-Test

Post-Test D iff.

5 4 -1 7 8 1 6 6 0 6 6 04 5 1 9 9 0 5 6 1 6 6 09 9 0 7 8 1 5 5 0 6 6 09 7 -2 8 9 1 5 5 0 6 6 05 9 4 8 11 3 6 6 0 6 6 0

U « 8, < X = .420 N.S . U = 12.5, 04 = 1.00 N.S.

Category III--O rganization of Physical and Temporal Environment

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D iff. Test Test D iff.

2 4 2 3 3 02 5 3 3 5 24 4 0 2 4 23 4 1 3 4 13 5 2 4 6 2

U = 11, OC- = .821 N.S.

Category V--Maternal Involvement with Child

Addicted Women Nonaddicted Women

Pre- Post- Test Test D iff.

Pre-Test

Post-Test D iff.

1 1 0 1 1 00 2 2 5 6 11 5 4 2 5 32 4 2 3 5 21 6 5 5 6 1

U = 7.5 04 = ,,31 N.S •

Category IV—Provision of Appropriate Play Materials

Addicted Women Nonaddicted Women

Pre- Post- Prer Post-Test Test D iff. Test Test D iff.

0 0 0 0 1 10 1 1 4 6 20 3 3 1 5 40 2 2 0 6 60 5 5 5 6 1

U = 11.5 r * =* .821 N.S.

Category VI—Opportunities for Varietyof Daily Stimulation

Addicted Women Nonaddicted Women

Pre- Post- Pre- Post-Test Test D iff. Test Test D iff.

3 3 0 1 3 20 3 3 4 4 02 2 0 2 2 02 0 -2 2 2 00 0 0 3 3 0

U = 11 6* = .842 N.S.

121

Mann Whitney U Test, (Table 19), no significant differences were found.

Therefore, Hypothesis 8 failed to be rejected.

No differences were found with respect to the mothers' compliance

with medical appointments and suggestions.

Hypothesis 9: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to their compliance with medical appointments and suggestions.

Alternative Hypothesis: Differences do exist betweennarcotic addicted women and nonnarcotic addicted women with respect to their compliance with medical appointments and suggestions. Narcotic addicted women comply less than nonnarcotic addicted women.

When scores of the two groups of women were analyzed by means of Mann

Whitney U Test, (Tables 20a and 20b), Hypothesis 9 failed to be rejected.

Therefore, there is no difference between narcotic addicted women and

nonnarcotic addicted women with respect to their compliance with

medical appointments and suggestions.

Differences between narcotic addicted infants and nonnarcotic

addicted infants were not found in all of the items, (Hypothesis 2a),

with some items differences were only found at specific ages of the

infants. On those items where Group effects were significant and

Group X Time effect was not significant, the general interpretation was

that infants of narcotic addicted women differed from infants of non­

narcotic addicted women at all ages or time periods. Significant

differences were found in favor of nonaddicted infants with respect to

the extent to which infants habituated to the presentation of aversive

stimuli (Items 1 and 3). Addicted infants demonstrated less mature

behavior than nonaddicted infants as they oriented toward animate and

inanimate visual and auditory stimuli (Items 6, 7 and 9). Addicted

122

TABLE 19

SCORES OF ADDICTED AND NONADDICTED NOMEN WITH WRIGHT ET AL. PARENT COUNSELOR HOME VISIT REPORT--ANALYZED

WITH MANN WHITNEY U TEST

Addicted NonaddictedWomen W omen

27 2727 2830 1426 2429 23

U = 5 <X.= .15, N.S.

123

TABLE 20a

SCORES OF ADDICTED AND NONADDICTED WOMEN WITH RESPECT TO COMPLIANCE WITH MEDICAL APPOINTMENTS

Addicted NonaddictedWomen Women

1 37 91 93 99 9

U = 4.5, Oi = .09, N.S.

TABLE 20b

SCORES OF ADDICTED AND NONADDICTED WOMEN WITH RESPECTTO COMPLIANCE WITH MEDICAL SUGGESTIONS

Addicted NonaddictedWomen Women

3- 59 95 95 99 9

U = 7, CX = .310, N.S.

124

infants exhibited more activity (Item 20) during the examining sessions

and were less able to utilize hand-to-mouth maneuvers for consoling

themselves than nonaddicted infants (Item 26).

Significant Group X Time interactions, whether or not in the

presence of significance for group, are somewhat more difficult to

explain. One interpretation might be that infants of narcotic addicted

women differed from infants of nonnarcotic addicted women, but not

necessarily at all ages. Alternatively, one could conclude that there

were differences due to the age of the infant (time period at which

measurements were obtained), but that this difference either did not

occur or was of a different magnitude for one or another of the groups.

Significant differences were found between the two groups in favor

of nonaddicted infants'as the ages of the infants increased. Between

age three days and three weeks both groups of infants increased their

level of performance in orienting toward the sound of the human voice

(Item 8), in alertness (Item 10), in Motor Maturity (Item 12) and in

self-quieting behavior (Item 25). With items 5, 8, 10, 12 and 25 both

groups of infants appeared to demonstrate similar configurations of

behavior (Figure 11, for example). Levels of differences however were

evident on the basis of addiction status of their mothers, with

nonaddicted infants demonstrating higher levels of performance than

addicted infants.

Both groups of infants were able to right their heads upon being

pulled into a sitting position (Item 13). Addicted infants cuddled in

the arms of the examiner less readily than nonaddicted infants (Item 14),

and little change in that behavior was demonstrated over time (Figure 12).

125

Direction of differences were found to increase in defensive behaviors

exhibited by both groups of infants (Item 15).

Analysis of results indicated that addicted infants exhibited a

higher level of arousal at age three days than nonaddicted infants

(Initial State, Hypothesis 2b). At age three days the infants' scores

were different in favor of nonaddicted infants. This means that

addicted infants were initially in an awake state, and engaged in

behaviors which ranged from exhibiting motor activity with thrusting

arm and leg movements to intense crying behavior. Cuddling by the

examiner was often necessary to aid in moving the infant into a sleep

state prior to beginning the assessment. Nonaddicted infants exhibited

behaviors which ranged from deep sleep to light sleep with eyes closed

at initial assessment.

It is noteworthy that initial state scores differed only at age

three days between the groups of infants. Higher state scores by the

addicted infants suggest that they were exhibiting a higher level of

arousal than nonaddicted infants within three days after birth and while

still in the hospital. It is possible that addicted infants may have

been experiencing transient effects of withdrawal. Their higher

initial state scores tend to suggest that they were exhibiting some

evidence of sleeplessness, a factor which has been found in other

studies of infants of narcotic addicted women.

With reference to Hypothesis 3, no differences were found between

Mental Development of the infants, on the basis of Bayley Scales of

Infant Development at either one month, 24 days or at three months.

Although Hypothesis 3 failed to be rejected, differences were found

126

between the two time periods. Part of the basis for this gain may

have been related to what appeared to represent an improved condition

of one of the infants in the addicted group. One of the infants

exhibited tremulousness that extended into the time period when the

initial Bayley Scale was administered (after one month of age), thus

lowering the scores at the first test period. Further, one infant

in the nonaddicted group failed to respond to several of the test

items at the first testing period, but made some changes with respect

to time. It is ultimately possible that the infants may have responded

to the activities provided by their mothers and thus showed some

changes with respect to the intervention program which was provided

for the infants and which may have been used by the mothers.

Results of analysis of Psychomotor Development, assessed with the

Bayley Scales were similar to results found on the Mental Scales of

the test. There were no differences between scores of groups of

infants, but there were significant differences with respect to time.

Infants in both groups earned higher scores at age three months (Mean =

125.4) than they did at one month, 24 days (Mean = 108). Time as well

as intervention appears to have made a difference with respect to

motor development as well as to mental development of the infants.

Infants were played with, handled, cuddled and talked with during the

three month period. Mothers were often observed imitating activities

of the home visitor with respect to working with their infants. It

therefore appears that some of such activities may have helped the

infants in some manner, as well as having provided ideas for the mothers

to imitate. It is realized that effects of maturation were expected

Ill

to be manifest; yet it also appears possible that the combined effects

of maturation and learning may have contributed to changes in the

infants' behavior.

There were no significant differences found with either of the

measures of maternal behavior as tested in Hypotheses 6, 7, 8 and 9. Inspection of Tables 16, 17, 18, 19, 20a and 20b shows that there were

some changes in scores between pre- and post-test periods, however,

they did not vary between the groups. It appears that addiction status

of the women in this study may not have discriminated finely between

the groups with respect to data derived from the instruments chosen.

However, inspection of Table 18, Category I--Emotional and Verbal

Responsivity, reveals that two addicted women received negative changes.

Circumstances in their lives were operating at the end of the study.

One mother who received a difference of -1, had contacted pulmonary

tuberculosis at the end of the study. During the last visit to her

home she appeared depressed and primarily involved with her own personal

problems and showed little concern for her infant. Another women, who

earned a difference of -2 with the same category appeared to have returned to drug use and appeared only minimally involved with her

infant. She had placed the baby with an older woman and appeared to

have removed herself from involvement with the infant. These two cases

seemed different from the others, and perhaps study of a larger sample

of women may have made a difference between the mothers.

A further explanation for lack of differences inchanges may be

related to selection of the sample. At the outset of the study efforts

were directed toward selecting women who would be similar along several

128

dimensions. Inspection of Table 1 shows that many women in the study

were supported by Public Welfare. When visiting homes one could easily

observe presence in the study of people from a low socioeconomic

strata with small resources available to them.

Finally, differences may have been found between the women had

the study included provisions for testing differences between the groups

at pre-test and post-test periods. For example, inspection of Table 17,

Ainsworth Scale MA-2 Mother's Delight in Baby, reveals that a pre-test

addicted women received scores which were of a lower magnitude that

nonaddicted women. Further study may include provision for determining

whether statistical differences are found.

Infants in this study differed along several dimensions on the

basis of addiction status of their mothers. Addicted infants demon­

strated less mature behavior than nonaddicted infants as they habituated

to the presentation of aversive stimuli and when they oriented toward

animate and inanimate visual and auditory stimuli. Addicted infants

were more active during examining sessions and were less able to

utilize hand-to-mouth movements to aid in consoling themselves than

nonaddicted infants. Addicted infants cuddled in the arms of the

examiner less readily than nonaddicted infants. Also, addicted infants

exhibited a higher level of arousal (higher initial state score) at age

three days than nonaddicted infants. Higher scores with the initial

state item may have been related to effects of narcotic withdrawal.

No differences were found between the groups of women with respect

to their feelings of competency for providing caregiving skills to their

infants, with respect to maternal care behaviors with respect to the

129

arr.ount oC cognitive and emotional support available within their homes,

the extent to which they accepted an intervention program or the extent

tc which they exhibited compliance with Medical appointments and

sugges tions.

Although only one examiner performed all assessments in this study,

rigid adherence to administration and scoring guidelines was maintained

throughout the study. Such strict compliance served to minimize biases

which may have arisen and had their effect on the findings of this study.

Intervention Results

There were changes in infant behavior at the completion of the

intervention program. Both groups of infants increased their levels

of performance over the four age periods with respect to orienting

toward the sound of a human voice. The infants became more alert and

exhibited more mature motor maturity, more selfquieting behavior and

were better able to bring their heads to the midline of their bodies

as their ages increased. Also, both groups of infants increased in

their use of defensive movements for removing a cloth from their faces.

The infants demonstrated improved behavior with the Bayley Mental

and Motor Scales. The combined initial scores for both groups of

infants with the Mental Scales was 85.1. After intervention their

scores had risen to 94.4, thus, an increase of 9.3 points was evident

after completion of the project.

Initially the combined mean score with the Motor Scales was 108.

Their mean score rose to 125.4 at the end of intervention, thus showing

a gain of 7.4 points.

While it is difficult to separate changes which may have occurred

130

as a result of maturation, nevertheless it appeared important to have

observed spontaneous activity by some mothers as they Imitated many

activities which were performed by the investigator when working with

their infants. It therefore, seems reasonable that some maternal

behaviors may have aided in contributing to changes which were demon­

strated in infant performance, and reflected in increased score values.

Feasibility of Planning and Implementing a Home-Based Intervention Program

In consideration of effort devoted by mothers with regard to

working with their infants, and in cooperating with the investigator

during this preliminary study, there were periods of anxiety associated

with the question of potential harm, observed especially by persons

who appeared to be visitors in some of the homes, and by some family

members, especially those who were lost to follow-up. Therefore some

benefit may be derived from considering the provision of a team of at

least two persons to visit homes of drug addicts during subsequent

studies, especially if those addicts are young adults.

Also, the provision of transportation of the women and their

infants to and from hospital based baby clinics may aid in assuring

that the infants receive recommended medical evaluations and treatments

at designated age periods.

CHAPTER V

a n d i m p l i c a t i o n s

The purpose in this study was to determine whether a difference

was found between development of infants born to narcotic addicted

women and infants born to nonnarcotic addicted women. The purpose

was also to determine whether changes were evident after pre- and

post-tests of mothers and their infants after they participated in an

intervention program. A third purpose was to examine the feasibility

of a subsequent study.

Instructional materials were developed and utilized in a home

based program directed toward strengthening mothering or helping

mothers become sensitive to infant needs, and helping mothers develop

caregiving skills to their infants. The subjects were ten infants and

their mothers. Five of the infants were born to narcotic addicted

women and five were born to women who presented no known history of

narcotic addiction. Nine of the families in this study were Black and

one was Caucasian, who were from low social position as defined in this

study by Hollingshead (1957).

Data were gathered during three phases. Phase I included the

pregnancy period of the mothers; Phase II included the hospital maternity

room contact with the mothers after delivery of their infants; and

Phase III which began in the homes of the infants at age one week,

131

132

after the mothers and infants were discharged from the hospital and

continued throughout the first three months of the infants' lives.

Three instruments were used for collecting infant data. They

were: 1) Amiel-Tison Neurological Maturity of Newborn Infants;

2) The Brazelton Neonatal Assessment Scale and 3) The Bayley Scales of

Infant Development— Mental and Motor Scales. Eleven instruments were

used to gather maternal data. The instruments were: 1) Hock Infant

Care Inventory; 2) Six Ainsworth Maternal Care Scales, a) Scale MA-1

Mother's Perception of Baby, b) MA-2 Mother's Delight in Baby, c) MA-3

Mother's Acceptance of Baby, d) MC-1 Mother's Availability to Baby,

e) MC-3 Amount of Interaction Offered by Mother, and f) MC-4 Appro­

priateness of Mother's Initiation of Interaction; 3) The Caldwell et al.

Inventory of Home Stimulation; 4) A Parent Counselor Home Visit Report,

adapted from Wright et al. (1970); and 5) Mother's Compliance with

Medical Appointments and Compliance with Medical Suggestions.

Data from ten infants and their mothers were analyzed through

several statistical techniques. Significant differences were found

between infants of narcotic addicted women and infants of nonnarcotic

women with respect to functioning with several items in the Brazelton

Neonatal Behavioral Scale. All differences were found to be in favor

of nonaddicted infants. Addicted infants habituated to the presentation

of aversive stimuli less often than nonaddicted infants, Addicted

infants were more active during the examining sessions and utilized

less applicability of consoling techniques than nonaddicted infants.

Both groups of infants progressively improved their capability of

133

orienting toward the sound of the examiner's voice, became more alert

and demonstrated improved motor movements during the intervention

period.

Although addicted infants cuddled in the examiner's arms less

readily and demonstrated higher levels of arousal than nonaddicted

infants, addicted infants were similar to nonaddicted infants in their

increased capability to remove a cloth from their faces as a defensive

maneuver.

No differences were found with respect to groups of infants when

assessed with the Bayley Mental and Motor Scales. However, there were

differences across time periods with both of the Bayley Scales. Both

groups of infants demonstrated higher scores across time. Group

differences were found with respect to the Visual Following skills from

the Bayley Scales of Infant Development. Addicted infants visually

followed objects less often than nonaddicted infants.

Hypotheses 2a, 2b and 4 were rejected because differences were

found with respect to infant behavior.

Hypothesis 2a: There is no difference between performancewith the 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to narcotic addicted women and performance with the 27 behavioral items (as assessed with the Brazelton Neonatal Behavioral Assessment Scale) of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

Hypothesis 2b; There is no difference between performance with the Brazelton State items of infants born to narcotic addicted women and performance with the Brazelton State items of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

134

Hypothesis 4: There is no difference between VisualFollowiny skills (as assessed with the Bayley Scales of Infant Development) of infants born to narcotic addicted women, and Visual Following skills (as assessed with the Bayley Scales of Infant Development) of infants born to nonnarcotic addicted women at age three months.

No differences were found with respect to neurological maturity at

birth between the two groups of infants. Nor were differences found

with respect to Mental and Motor Development between the groups of

infants. Therefore, Hypothesis 1, 2c, 3 and 5 failed to be rejected.

Hypothesis 1: There is no difference between neurologicalmaturity at birth, of infants born to narcotic addicted women (as assessed with the Amiel-Tison Neurological Evaluation of the Maturity of Newborn Infants) and neurological maturity at birth of infants born to non­narcotic addicted women (as assessed with the Amiel- Tison Neurological Evaluation of the Maturity of Newborn Infants).

Hypothesis 2c: There is no difference between performancewith Brazelton "Elicited Responses" of infants born to narcotic addicted women and performance with Brazelton "Elicited Responses" of infants born to nonnarcotic addicted women at four age periods (three days, one, two and three weeks).

Hypothesis 3: There is no difference between MentalDevelopment (as assessed v;ith the Bayley Scales of Infant Development) of infants born to narcotic addicted women and Mental Development (as assessed with the Bayley Scales of Infant Development) of infants born to nonnarcotic addicted women at two age periods (one month, 24 days and three months).

Hypothesis 5: There is no difference between PsychomotorDevelopment (as assessed wTith the Bayley Scales of Infant Development), of infants born to narcotic addicted women and Psychomotor Development (as assessed with the Bayley Scales of Infant Development), of infants born to non­narcotic addicted women at two age periods (one month,24 days and three months).

No significant differences were found between narcotic addicted

women and nonnarcotic addicted women with respect to their feelings of

135

competency as measured with the Hock Infant Care Inventory, with

respect to their maternal care behaviors as measured with six Ainsworth

Scales, with respect to their home environments, as measured with the

Inventory of Home Stimulation, with regard to their acceptance of an

intervention program, assessed with a Parent Counselor Home Visit

Report from Wright et al., or with respect to their compliance with

medical appointments and suggestions. Hence, Hypotheses 6, 7, 8 and 9failed to be rejected.

Hypothesis 6: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to their feelings of competency for providing caregiving skills, as assessed with the Hock Infant Care Inventory.

Hypothesis 7a: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to amount of change in charcteristics of mothering, derived from pre- and post-tests (as assessed with Ainsworth Maternal Care Scales: Perception of Baby, Delight in Baby, Availabilityto Baby, Acceptance of Baby, Amount of Interaction with Baby, and Appropriateness of Mother's Initiation of Interaction with Baby).

Hypothesis 7b; There is no difference between narcotic addicted women and nonnarcotic addicted women with respect to changes in characteristics of mothering assessed with the Caldwell et al. Inventory of Home Stimulation.

Hypothesis 8: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to their acceptance of home training (as assessed with a Parent Counselor Home Visit Report-- Wright et al.)

Hypothesis 9: There is no difference between narcoticaddicted women and nonnarcotic addicted women with respect to their compliance with medical appointments and suggestions.

Implications

Some of the results of this preliminary study may contribute to

subsequent studies of narcotic addicted women and their infants. The

oIlowing recommendations are offered;

1) Perform a replication of this study with a period of interven­

tion to extend beyond three mouths. Opportunities for helping

mothers with their infants beyond that age level are needed.

At the end of the present study some of the infants had

reached a developmental level where they had begun to respond

to adult intervention with vocalizations and appeared ready

to benefit from further intervention. A longer period of

involvement may have increased impact on the development of

the infants, since infants may be more responsive at older ages.

In addition, a larger sample of infants seems desirable.

While conservative statistical tests were employed whenever

possible in order to minimize alpha error, finding differences

where none in fact exist, if cannot be gainsaid that a very

large number of tests were performed on only ten infants. Beta

error, failing to find differences that in fact exist, could

not be minimized simultaneously with alpha error and may be

quite large. The only way to reduce both types of error is

to increase the number of infants studied.

2) Another direction for future research might include directing

data analysis to determine whether a relationship is found

between availability of emotional and cognitive support

available within the infant's home (as assessed with the

Inventory of Home Stimulation), and infant performance at pre­

school age. Such a finding might aid in devising strategies

for encouraging mothers toward manipulating their home environ­

ments for the benefit of their infants.

137

3) Analysis of daLa might also include determining whether a

relationship is found between mother responses to Ainsworth

ScaLes and infant development at preschool age.

4) Analysis of mothers' feelings of competency with the Hock

Inventory may include obtaining separate scores for each of

the caregiving skills. That information might provide some

knowledge concerning whether mothers feel more competent with

respect to some caregiving skills than with others found on

that Inventory.

5) Perhaps a more basic need may exist with respect to extending

social action which would provide help in motivating addicted

women to develop productive life styles. Although some help

seems available through drug treatment centers as evidenced

by those centers which provided help with this study, it

appears that the question of how to best serve the needs of

addicted women may remain unanswered.

6) A further direction for research, if ethical, might attempt to study whether infants of narcotic addicted women should be

removed from their mothers and placed in foster homes, as has

been suggested by some writers, or whether or not infants should

remain with their mothers.

7) The administration of neurological examinations at a later

age of the infants may be of some value.

8) Extended knowledge concerning behavior of addicted infants may be gained from a similar study as the present but which would

include the use of a second control group. That group might

138

be studied without a component of intervention strategies.

Results of such a study might aid in determining possible

effects of an intervention program on addicted infants,

further research may attempt to provide answers to the following

questions:

1) Are there significant differences in behavior of infants whose

mothers have consumed drugs other than heroin during pregnancy?

2) Do addicted mothers who have only one child, differ significantly

from addicted mothers who have multiple children, with respect

to behaviors assessed by means of:

a) The Infant Care Inventory?

b) Six Ainsworth Scales utilized in this study?

c) The Caldwell et al. Inventory of Home Stimulation?

d) The Parent Counselor Home Interview Report (Wright et al.)?

e) Mother's Compliance with Medical Appointments and Suggestions?

APPENDIX I

NEUROLOGICAL EVALUATION OF THE MATURITY OF NEWBORN INFANTS

139

NEUROLOGICAL EVALUATION OF ’ THE •\ATURITY OF NEWBORN INFANTS

omo m a t e uiiivlk;>iiy clinic456 C l in ic Drive ^Columbus, O hio 43210

APPENDIX IIINAME:M0T| 1 LRi ‘BIRTHDATE: _ ______________

DATE OF EXAM

v #* f ̂,l_ r

celc Q

O r.O:

ccJ iiM̂I

. '.rr sJ^| fwll »•'*\orJ'

» 1« |l«"Ol' H'f „ Nt.O* *■'«*i»» 4»4 !•»' JO »«C|l> o*1 •••| r ' l « *•1

Pn.'Jsive Tone

4 »'WM

titi • *.« •*i ir-*M» iCft ®* V.*!!

III*1t*c*<* ,•« • % * f' • » «* • I*o • -w k I,.L̂ ,* * H« I \\m h» »«**<♦•* II '• w<*4 •'*mi4 Vm m M

.1

\u i»f Cil11 ’ i»j* ,lliCi li l̂

Active Tone

S P 8 9 5From: Amici-Tison, C . . Iteiiroloyicnl Evaluation of the

Maturity o£ Newborn Infants. Arch. Dir;', chiIdh .’( 43 :09,1960.

APPENDIX II

BRAZELTON NEONATAL BEHAVIORAL ASSESSMENT SCALE AND SCORE SHEET

141

PLEASE NOTE:

Pages 142-151, "Brazelton Neonatal Behavioral Assessment Scale", pages 152-161, "Inventory of Home Stimulation, pages 162-181, "Ainsworth Scales" and pages 197-209, "Hollingshead Two Factor Index of Social Position" all previously copyrighted, not microfilmed at request of author. Available for consultation at the Ohio State University Library.

UNIVERSITY MICROFILMS.

APPENDIX X

PARENT COUNSELOR HOME V i!SIT REPORT

182

183

Mother's Name

PAM 1:1 NT COUNSELOR HOME VISIT HE PORT

____________________C h i l d ' s Name _

D a t e o f Vi . s i t

Col. ____ The visit was

______ 1. Successfully made; mother was at home.

2. Mother was not at home but visited with someone else.

3. No one was at home; visit was not made.

______ 4. Someone was at home, but no visit made.

Col. ____ The mothering one

______ 1, Was warm, receptive, cooperative

2. Worked with (tolerated parent counselor)

______ 3. Showed little concern

______ 4. Made fun of parent counselor's ideas

_____ 5. Was openly hostile to parent counselor's ideas.

Col. The visit was

______ 1. Not delayed

______ 2. Delayed due to care of the children

______ 3. Delayed due to housework

______ 4. Delayed due to talking with friends or relatives

______ 5. Delayed due to getting dressed

6. Delayed due to other reasons

184

Today's visit was with

A mother who normally cares tor child most of the time.

A mother who docs not normally care lev the child.

Someone else who normally cares for the child most of the time.

Temporary baby sitter--probably paid.

How much activity was in the room in which you presented the exercises?

Nothing was going on beside the training.

Other activities were going on but did not distract attention of the baby.

Other activities in the room often pulled the baby's attention away from the training.

There was such a great deal of activity in the room that presenting the exercises was difficult.

How many interruptions were there during the task training period?

None

One or two

Three or four

There was almost always distraction in the home.

What was the most frequent or longest interruption?

There were no interruptions.

Mothering one had to care for another child.

An adult wanted something.

The phone rang.

Visitors came.

The child had to be fed.

185

The child went: lo sleep.

A d i stracu Lnc TV show, roc :nv. player or radio.

'.X iri.n ,: Che is i L , t iie m o t h e r : a i one was

Present all of the time.

Present most of the time.

Present part of the time.

Mot present.

During the visit, the father was

Present all of the time.

Present most of the time.

Present part of the time.

Mot present.

During the visit the father was

Interested in the training and wanted to help.

Interested but did not take an active part.

Mot interested but did not interrupt the training.

Not interested and interrupted the training for something trivial,

Openly hostile against the training and tried to disrupt and/or distract it.

Thought the training was foolish but did not interfere with it.

Mot applicable, no father present.

How did the mothering one react to instruction?

Was attentive while you were talking and asked questions, or made comments (favorable).

1.86

Did other th Logs while parent counse lor was demonstrnt ini; materials (straightened child's cLothers, looked around the room, did housework), Listened without comment,

Walked out of the room during a demonstration suss ton.

Refused to perform the task.

Laughed at instructions.

Asked the mothering one how the child responded to last visit demonstrations.

Showed evidence of response.

Showed no evidence of response.

Not applicable-new child in the project.

When the mothering one uses materials from the previous visit she

Becomes discouraged if the child does not respond during the first presentation.

Is satisfied, even though the child did not respond as well as she thought desirable.

Tries several times until she observes some type of response.

Continues to work with the task even after the child performs well.

What is the mothering one's verbalized attitudes toward the project?

Believes the project is great.

Believes it is OK.

Appears only moderately interested in the project.

Does not comment regarding the project.

APPENDIX XI

INFANT CARE INVENTORY

187

1S8

IMFANT CARE INVENTORY

Select: the one person in each pair that you feel could SHOW AFFECTIONTO YOUR RASY better:

YOURSELF ( ) OR ( ) BABY'S GRANDMOTHER

BABY'S GRANDMOTHER ( ) OR ( ) DAY CARE TEACHER

EXPERIENCED BABY SITTER ( ) OR ( ) FATHER

DAY CARE TEACHER ( ) OR ( ) YOURSELF

PEDIATRIC NURSE ( ) OR ( ) EXPERIENCED BABY SITTER

BABY'S GRANDMOTHER ( ) OR ( ) FATHER

DAY CARE TEACHER ( ) OR ( ) FATHER

EXPERIENCED BABY SITTER ( ) OR ( ) BABY'S GRANDMOTHER

FATHER ( ) OR ( ) YOURSELF

PEDIATRIC NURSE ( ) OR ( ) BABY'S GRANDMOTHER

FATHER ( ) OR ( ) PEDIATRIC NURSE

EXPERIENCED BABY SITTER ( ) OR ( ) DAY CARE TEACHER

YOURSELF ( ) OR ( ) PEDIATRIC NURSE

S9

Select the one person in eacli pair that you feel, could PREPARE YOURCHILD AND PUT IITM/HER TO BED better:

YOURSELF

FATHER

PEDIATRIC NURSE

YOURSELF

PEDIATRIC NURSE

BABY'S GRANDMOTHER

EXPERIENCED BABY SITTER

DAY CARE TEACHER

DAY CARE TEACHER

YOURSELF

FATHER

EXPERIENCED BABY SITTER

PEDIATRIC NURSE

BABY'S GRANDMOTHER

EXPERIENCED BABY SITTER

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

BABY'S GRANDMOTHER

PEDIATRIC NURSE

EXPERIENCED BABY SITTER

PEDIATRIC NURSE

BABY'S GRANDMOTHER

FATHER

DAY CARE TEACHER

YOURSELF

FATHER

EXPERIENCED BABY SITTER

YOURSELF

BABY'S GRANDMOTHER

DAY CARE TEACHER

DAY CARE TEACHER

FATHER

190

Sc l a d the one person in each pair that you reel could CALM YOUR BAPbe tier:

FAT! IKK

EXPERIENCED BABY SITTER

BABY'S GRANDMOTHER

PEDIATRIC NURSE

YOURSELF

PEDIATRIC NURSE

EXPERIENCED BABY SITTER

YOURSELF

BABY'S GRANDMOTHER

PEDIATRIC NURSE

YOURSELF

FATHER

DAY CARE TEACHER

EXPERIENCED BABY SITTER

DAY CARE TEACHER

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

OR

FATHER

DAY CARE TEACHER

EXPERIENCED BABY SITTER

PEDIATRIC NURSE

DAY CARE TEACHER

DAY CARE TEACHER

BABY'S GRANDMOTHER

FATHER

BABY'S GRANDMOTHER

EXPERIENCED BABY SITTER

PEDIATRIC NURSE

YOURSELF

BABY'S GRANDMOTHER

FATHER

191

Select the one person in each pair that you feel could DIAPER YOUR BABYbetter:

YOURSELF ( ) o? ( ) EXPERIENCED BABY SITTER

FATHER ( ) OR ( ) PEDIATRIC NURSE

EXPERIENCED BABY SITTER ( ) OR ( ) BABY'S GRANDMOTHER

FATHER ( ) OR ( ) YOURSELF

YOURSELF ( ) OR ( ) BABY'S GRANDMOTHER

EXPERIENCED BABY SITTER ( ) OR ( ) DAY CARE TEACHER

YOURSELF ( ) OR ( ) PEDIATRIC NURSE

PEDIATRIC NURSE ( ) OR ( ) BABY'S GRANDMOTHER

DAY CARE TEACHER ( ) OR ( ) YOURSELF

DAY CARE TEACHER ( ) OR ( ) FATHER

PEDIATRIC NURSE ( ) OR ( ) DAY CARE TEACHER

EXPERIENCED BABY SITTER ( ) OR ( ) FATHER

BABY'S GRANDMOTHER ( ) OR ( ) DAY CARE TEACHER

BABY'S GRANDMOTHER ( ) OR ( ) FATHER

PEDIATRIC NURSE ( ) OR ( ) EXPERIENCED BABY SITTER

192

i 1".: o.io por.s...-i in cacli )L i\ i\.iiS oct c-ju ;

pair Liint: you fuel couLd UNDERSTAND '

nub ( ) ox ( ) BABY'S GHANDMiU'ilER

FATHER ( ) OR ( ) PEDIATRIC NURSE

EXPERIENCED BABY SITTER ( ) OR ( ) BABY'S GRANDMOTHER

FATHER ( ) OR ( ) YOURSELF

BABY'S GRANDMOTHER ( ) OR ( ) FATHER

YOURSELF ( ) OR ( ) EXPERIENCED BABY SITTER

PEDIATRIC NURSE ( ) OR ( ) BABY'S GRANDMOTHER

DAY CARE TEACHER ( ) OR ( ) YOURSELF

DAY CARE TEACHER ( ) OR ( ) FATHER

YOURSELF ( ) OR ( ) PEDIATRIC NURSE

EXPERIENCED BABY SITTER ( ) OR ( ) FATHER

PEDIATRIC NURSE ( ) OR ( ) DAY CARE TEACHER

BABY'S GRANDMOTHER ( ) OR ( ) DAY CARE TEACHER

PEDIATRIC NURSE ( ) OR ( ) EXPERIENCED BABY SITTER

EXPERIENCED BABY SITTER ( ) OR ( ) DAY CARE TEACHER

yourse! j- ( ) om

EXPERIENCED BABY SITTER ( ) OR

YOURSELF ( ) OR

PEDIATRIC NURSE ( ) OR

BABY'S GRANDMOTHER ( ) OR

PEDIATRIC NURSE ( ) OR

FATHER ( ) OR

YOURSELF ( ) OR

PEDIATRIC NURSE ( ) OR

DAY CARE TEACHER ( ) OR

EXPERIENCED BABY SITTER ( ) OR

DAY CARE TEACHER ( ) OR

FATHER ( ) OR

EXPERIENCED BABY SITTER ( ) OR

BABY'S GRANDMOTHER ( ) OR

FATHER

BABY 1S C-RANDMOT HER

EXPERIENCED BABY SITTER

DAY CARE TEACHER

BABY'S GRANDMOTHER

YOURSELF

EXPERIENCED BABY SITTER

DAY CARE TEACHER

BABY'S GRANDMOTHER

BABY'S C-RAXDMOTHER

YOURSELF

PEDIATRIC NURSE

DAY CARE TEACHER

FATHER

) 01;

PEDIATRIC NURSE ( ) OR

EXPERIENCED BABY SITTER ( ) OR

DAY CARE TEACHER ( ) OR

YOURSELF ( ) OR

DAY CARE TEACHER ( ) OR

PEDIATRIC NURSE ( ) OR

BABY'S GRANDMOTHER ( ) OR

YOURSELF ( ) OR

BABY'S GRANDMOTHER ( ) OR

YOURSELF ( ) OR

EXPERIENCED BABY SITTER ( ) OR

PEDIATRIC NURSE ( ) OR

FATHER ( ) OR

EXPERIENCED BABY SITTER ( ) OR

DAY CARE TEACHER

BABY’S GRANDMOTHER

FATHER

BABY'S GRANDMOTHER

YOURSELF

EXPERIENCED BABY SITTER

DAY CARE TEACHER

PEDIATRIC NURSE

FATHER

EXPERIENCED BABY SITTER

FATHER

BABY'S GRANDMOTHER

PEDIATRIC NURSE

DAY CARE TEACHER

195

p a i r t h a t you 1'oeL c o u ld P! U] VMF_APP!!0- BABY b e t t o r :

S e l e c t th e one p e rs o n i.n each PH I. ATE VISUAL AND VERBAL SIIMLL,-

pi: n la th i t : nurse i

DAY CARE TEACHER (

BABY'S GRANDMOTHER (

day care TEACHER (

BABY'S GRANDMOTHER (

EXPERIENCED BABY SITTER (

FATHER (

YOURSELF (

PEDIATRIC NURSE (

YOURSELF (

PEDIATRIC NURSE (

EXPERIENCED BABY SITTER (

YOURSELF (

OR ( ̂ DAY CASE TEACHER

OR ( ) FATHER

OR ( ) DAY CARE TEACHER

OR ( ) YOURSELF

OR ( ) FATHER

OR ( ) FATHER

OR. ( ) YOURSELF

OR ( ) BABY'S GRANDMOTHER

OR ( ) EXPERIENCED BABY SITTER

OR ( ) EXPERIENCED BABY SITTER

OR ( ) BABY'S GRANDMOTHER

OR ( ) DAY CARE TEACHER

OR ( ) PEDIATRIC NURSE

)

APPENDIX XII

HOLLINGSHEAD W O FACTOR INDEX OF SOCIAL POSITION

196

APPENDIX XIII

PARENT INTERVIEW REPORT

210

211

PARENT INTERVIEW REPORT

Name o£ Parent _______ ___________Name of Infant

Date of Birth_____________________ Date of Birth

Place of Interview Sex of Infant

( ) 1. FAMILY INFORMATION (Mother's parents)

Father:

a) living at homeb) deceasedc) not living at home; whereabouts knownd) whereabouts unknowne) other

( ) Mother:

a) living at homeb) deceasedc) not living at home; whereabouts knownd) whereabouts unknowne) other

( ) Birth Order:

a) oldestb)c) youngest

( ) 2. MARITAL STATUS (Infant's parents)

a) singleb) married, living with first spousec) married, not living with first spoused) married, living with second spousee) divorcedf) widow

( ) 3. NUMBER OF CHILDREN

4. Have any of your children living with persons other than yourself for any length of time? ______________________If so, with whom and for how long?

212

( )

( )

( )

5. C PI/C AT [OX

a) less than 3 yearsb) A-8 yearse) some high school or technical schoold) hi ah school graduatee) some college or technical school after high schoolf) graduate school or some graduate credit

6. REASON FOR LEAVING SCHOOL

a) still in schoolb) graduatedc) expelledd) dropped oute) other------------ specify

7. OCCUPATION -- Are you employed? Yes Mo

a) Is husband employed? Yes No

Place of Employment _____________________

Title of Position

8. DRUG EXPERIENCE

a) Age of first experienceb) First drug used by you

11. JUST PRIOR TO DELIVERY OF YOUR BABY, WHEN DID YOU RECEIVE YOUR LAST DRUG INTAKE?

a) the same dayb) one day before that timec) two days before that timed) other ___________________________________

c)9. OCCASION OF FIRST EXPERIENCE

a) curiosityb) enticed by friendc) in hospitald) for sleep

e) depressionf) for "kicks"g) dare

( ) 10. WHICH WAS THE SECOND DRUG USED BY YOU?

a) no change in drug use after first

213

( ) 12.

( ) 13.

( ) 14.

HOW DID YOU MANAGE TO STOP TAKING DRUGS?

a) participated in drug programb'l other______________________________o') If you participated in a drug program how did you

decide to do so?1) self imposed2) other ___________________________

WHILE PARTICIPATING IN THE PROGRAM DID YOU USE DRUGS?

a) Yesb) No

WITH WHOM DO YOU NOW LIVE?

a) Husband and children (or child)b) Parents (specify which)____________c) Other persons (specify) ____________

Adapted from: Bloom, William A., Jr., and Sudderth, E. Ward, "Methadonein New Orleans," in Stanley Einstein, Methadone Maintenance. New York; Marcel Dekker, Inc., 1971.

APPENDIX XIV

BOOKLET FOR MOTHERS

214

H H E L P t t A

D S I D

B O O K L E T

216

ACTIVITIES WITH INFANTS

This booklet is planned for parents of infants and very youngchi Ldren. T'.'.e ideas chat are Lnc Luded have come from experiences ofr.a-.y people who have been studying Infants and children for many years.Ihe activities in this booklet provide games that are fun for parents and their infants and at the same time provide learning as well.

The games are intended to help your baby develop some basic skills such as focusing his eyes on objects and coordinating his eyes with his hands. You will discover that baby learning is enjoyable and you will note that the child may seem to develop confidence in himself in knowing that he can do certain things in a skillful manner.

We suggest the following ideas:

Make learning a fun time. When your infant seems no longer interested, try another activity or stop playing completely. Your baby may be interested for only five minutes.

BABIES NEED LOVE

A baby's great need in life is love, affection and good physical care. Being loved and cuddled helps a baby learn to live with the world. Your baby will learn about love from the attention that is given him, from the way you respond to him when he says he needs you by crying.

IMITATION

Your baby will not be able to imitate you when he is very young. You may imitate some of the things that he does. Imitate his smile and the sounds that he makes, and also his movements.

A caretaker's response to the infant's needs will help the infant if the responses are satisfactory to him. A smile, a pleasant voice or a hug are positive responses to the infant. Praising your infant is a satisfactory response to him.

YOUR BABY MAY PROVIDE SIGNALS FOR YOU

There are several situations about the management of your baby in which you may be interested, and those situations may have serious meaning for his development. Some of those situations are related to the special feelings that your infant may have. You will be able to judge some of his feelings by the act of crying.

217

Cry ini: Ls the infant's way of ceiling you that lie needs you for something. If he cries with low -.-.loans and sighs he may be sleepy.1: he cries and sucks his fists or fingers he may be hungry. He may be uncomforLable--he may be wet and cold and his diaper may need to be changed. His clothes may need to be straightened. lie may be crying because he wants some kind of attention from you. Talking to dim for a .few minutes may stop his crying. At an early age he is too young to tell you why he is crying.

When your baby was only a few days old he probably had a set schedule for feeding. If he was born in a hospital he may have been fed every three or four hours on a regular schedule. As he grows older he may need fewer feedings, especially at night. You may help your baby by handling his feeding in a way that seems satisfactory to him. He may be less fussy if you don't let him cry from hunger, just because it may not be time for his feeding. A check with your physician will help you with your feeding plans.

Your baby may cry because he may want you to hold and cuddle him. You may be helped in knowing that he wants you to cuddle him if he scops crying when he sees you.

Babies also cry when they don't have anything else to do. Pick dim up, hold him and talk to him. You need not feel a concern for spoiling him. Sometimes you may be able to comfort your baby by:

--placing your hand slightly on his stomach,

--holding his hands or

--talking to him.

Your baby will enjoy feeling warm and cuddled. As you cuddle him talk to him. He will soon smile at you when you talk to him.

The way you talk to your baby, the way you treat him and the way he gets along with other people in the family are very important to him.

The things you say to the baby will influence how he feels about himself.

r

lie will learn to like himself better if you talk to him in a soothing voice that lets him know that he is a part of a loving and secure home.

Hold him close to you and show him that you enjoy being with him. Teach him that you and your family are fun to be with. Help him to learn to like other people.

218

s rn c i 'S T io x s fo r s t im u l a t io n

To S I iinu late Fee lino.

Sni:i ■; c V-by ’ a pos it ion From stomach to back.

As you diaper him gently massage him.

Cuddle and hold him firmly; talk and sing to him while doing so.

Move his arms over his head and then back.

To Stimulate His Vision

Shift him to different places in his crib to allow light to be available to both of his eyes.

Remove his crib bumpers often to allow him to see objects near him.

Place a patterned sheet on his bed if available. (Such a sheet may be made by sewing scraps of colored materials on his sheet--a red shape, or any color that may be available with the home.

To Stimulate His Hearing

Sing to him as you do different things for him, such as diapering.

Say a nursery rhyme to him.

Say his name while talking to him.

Let your baby hear different sounds and develop listening skills.

Place a clock that ticks quietly beside his bed.

To Enjoy Your Baby

Be friendly with him and enjoy how he feels as you hold him.

Enjoy giving him his bath.

Shift his crib to different places in the room.

Take him outdoors (when your doctor says he is old enough); go for a walk with him.

Place him nearby while the family is eating (if he is awake).

Place him in the kitchen occasionally while you are preparing meals.

219

Take him w i t h you when v i s i t i n g • . •e la t i . ves.

Change and f e e d him f ro m a l t e r n a t e s i d e s .

EASY J.-Y'YS

While you are changing diapers, feeding or just playing with your baby, play a couching and talking game.

Put your infant's hand on your ear and say "Ear." Repeat this by putting his hand on his ear and repeating the word. Do the same for other bodily parts.

The caretaker's face is something that the child sees and learns to recognize. As you do simple touching and talking games he will be able to recugnize the parts of your face and notice that they feel different and their names sound different.

While he is placed on his back, move a colorful rattle, ball or other toy slowly in the head-to-foot direction; then from right- to-left. Do these movements several times. After he follows for a while move the object in a circular direction around the baby's head so that he will have to turn his head in order to see it. While moving the object talk gently to him even though he obviously may not understand the words.

As the baby becomes older he may enjoy the same activity over and over again. Adults may find this boring, but the child may contin­ually learn from repetition.

After the baby has learned to reach, make him "work" by placing an attractive toy beyond his reach. Provide small blocks (too large for him to swallow) for him to grasp.

Allow him to look at his image in the mirror.

Stand behind the infant and ring a bell, shake a rattle, a bunch of keys or any other noise maker. Let him find the direction of the sound by turning his body toward the sound. He will learn that his body may be used to find objects.

BABIES LEARN TO TALK

Babies know how to cry and make sounds. Babies may be encouraged to talk by parents and other caretakers. If you talk to your baby he will learn to make sounds.

When you are diapering, bathing and holding your baby, or just watching him lie in his crib making cooing sounds, respond to him by

220

s t r o k in .v h i s s tom ach , suit l i n y and m a k in g s i m i l a r sounds . l ie may r e p e a t h i s c o o i n : and you w i L l have a " c o n v e r s a t i o n " g o i n g . T h i s i s an easy a c t i v i t y and may be r e p e a t e d a t odd moments.

HASTES l e a k:: t h r o u g h t o u c h

A mother may help her newborn baby develop when she holds him close to her body. She helps him when she strokes his cheeks and rubs his hands and his body.

Babies learn through their skin. They learn by touching and feeling, linen they are held, stroked and cuddled they develop fast and feel safe.

Stroke his cheeks; rub his body when you bathe him. Babies will put toys in their mouths; give babies toys that are safe.

Keep things away from baby that he might swallow and that might make him sick.

Praise the child's effort; laugh and look proud when he does the movements that you want him to do. Try not to scold if he does not want to play.

PLAN ON REGULAR VISITS TO YOUR BABY’S DOCTOR

Although your baby is well, it is important that you take him to his doctor on regularly planned visits.

Your doctor will observe the baby's growth and development and will inform you about changes in care and feeding to fit your baby's par­ticular needs.

Regular visits to the doctor will provide opportunities for your to discuss problems and will help you gain confidence in caring for your baby.

THIS BOOKLET HAS PREPARED

3Y

STAFF MEMBERS IN

TILE HELP-A-BA3Y-PROJECT

For more information call 422-3152

APPENDIX XV

MOTHER'S compliance with medical appointments and suggestions

223

224

MrmiKR'S VOMPLIANCE WITH MEDICAL APPOINTMENTS

The v a r i a b l e b e i n c c o n s i d e r e d h e re i s the e x t e n t t o w h ic h th e m o th e r ( p c i . m a r i . l v ) , o r a c a r e t a k e r h r i n as t h e baby to the or. t - o a t i o u t c l i n i c a t The Oh io S t a t e U n i v e r s i t y H o s p i t a l s a c c o r d i n g to a p la n n e d s c h e d u le ,Tor the purpose of routine or non-routine medicaL examinations and other medical problems. During the first three months of the infants' lives two routine visits are scheduled by the Pediatrician with the mother's consent. Other visits are scheduled when the need arises and are determined when a request is made by the parent, or when in the opinion of the Pediatrician, a need exists for the infant to be scheduled prior to his routine visit.

A mother may agree to a scheduled visit but fail to effect the appointment due to many reasons. She may telephone and notify hospital personnel regarding her inability to keep the appointment, while on the other hand she may complete no effort regarding her reasons for failure to return the baby as scheduled.

It seems reasonable to assume that a difference in effort exists between the mother who is unable to make the visit, but notifies hospital personnel to that effect, and the mother who is unable to make the visit and who makes no contact with hospital personnel.

1. Very Low Effort; This rating will be given to a mother whofails to keep any of her scheduled appointments, does notnotify hospital personnel, but will offer a reason if initiative is assumed by hospital personnel for contacting her to reschedule another appointment.

3. Low Effort: This rating will be given to a mother who does notkeep her appointment, but will telephone the hospital within a few days after the scheduled visit, ask for another appoint­ment, provide no reason for failure to keep the previous appoint­ment, or makes the statement that she forgot the appointment.

5. Moderate Effort; This rating will be given to a mother whoarrives on the scheduled date, but within one-half to one hour after her scheduled time, and provides no reason for her tardiness.

7. High Effort; This rating will be given to a mother who arrives on the scheduled date within one-half and one hour late, provides a reason for her tardiness and is willing to wait until other patients are served, if necessary.

9. Very High Effort: This rating will be given to a mother whoarrives promptLy and is willing to wait even though the Pediatrician may be unavailable immediately on the scheduled time.

225

m c o m p u .axck medical suggestions;riuch as feeding, applying special medicat tons as directed and handling other child-centered problems within t h e hornel

The variable being considered is the extent to which the mother Tor other primary caretaker) follows directions provided by the research staff, such as handling infant discomfort due to several reasons; follows directions provided directly to the mother by medical personnel. Other suggestions to families may include seeking family aid, when specifically needed, from community organizations.

A mother may desire help with some of her children and may be provided with suggestions by the project staff. It is assumed that a difference in effort exists between the mother who tries to follow suggestions, and the mother who requests suggestions, but fails to make attempts to investigate further.

1. Very Low Iffort; This rating will be given to a mother whorequests aid, is provided with sources of availability, or materials to use in solving her problems but who fails to respond.

3* Low Effort; This rating will be given to a mother who needs aid as determined by obvious conditions such as observable infections on the infant, observable need for clothing, reported illness of her children since a previous contact, and who is provided with sources of aid, who makes contact with the source but does not follow through completely.

5. Moderate Effort; This rating will be given to a mother whoneeds and requests help, but follows only partially the sugges­tions provided for her.

7. High Effort; This rating will be given to a mother who needsand requests help and who follows most of the suggestions provid­ed and who offers reasonable explanations for lack of completion.

9. Very High Effort; This rating will be given to a mother whorequests help, follows directions and provides evaluations of the aid i-eceived.

226

MOTHER'S COMPLIANCE WITH MEDICAL APPOINTMENTS AND SUGGESTIONS

RATING FORM

Name of Parent ________________________ Name of Infant

Date of Birth

A. Mother's compliancewith medical appointments

(1) (3) (5) (7) (9)

B. Mother's compliancewith medical suggestions

APPENDIX XVI

TABLES 21-26 SUMMARY OF RESULTS OF ANALYSES OF VARIANCE ON BRAZELTON ITEMS 3, 6, 7, 9, 20 AND 26

227

With respect to Item 3, Response Decrement to Bell, addicted

infants (X = 3.75) were less able to shut down responses than were

nonaddicted infants (X = 5.55). When addicted infants were presented

the sound of a bell their responses were the same within the ten

trials, whereas nonaddicted infants shut down body movements within a

range between seven to ten presentations of the bell. See Table 21 for a summary of those results. ,

TABLE 21

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON ITEM 3— RESPONSE DECREMENT TO BELL

i

Source of Variation df MS F Significance

Group 1 32.40 13*16(8) p <.01

Time 3 .90 *89(3,24) N.S.Group X Time 3 .67 *66(3,24) N.S.

229Item 6 - Orientation Response-Inanimate Auditory

This item is a measure of the extent to which an infant orients toward the sound of an inanimate auditory stimulus— the sound of a rattle. Addicted infants (X = 3.85) stilled, brightened their eyes but made no attempt to locate the sound; nonaddicted infants (X - 5.75)

shifted their eyes to the sound as well as turned their heads. The

results are presented in Table 22.

TABLE 22SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON

ITEM 6— ORIENTATION RESPONSE— INANIMATE, AUDITORY

Source of Variation df MS F Significance

Group 1 36.10 24.47(8) p<.01Time 3 1.73 1,59<3,24) N.S.

Group X Time 3 3.03 2-78(3,24) N.S.

230Item 7 - Orientation— Animate Visual

This item assesses the infant's orienting toward an animate

object— a person's face. Addicted infants (X *= 2.60) responded by

stilling and brightening the eyes upon the presentation of examiner's

face within the line of the infant's vision; nonaddicted infants (X = 5.00) shifted their eyes to the sound as well as stilled and brightened their eyes. See Table 23 for a summary of results.

TABLE 23SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON ITEM 7— ORIENTATION— ANIMATE VISUAL

Source of Variation df MS F Significance

Group 1 57.60 34.65(g) p <.001Time 3 3.87 2*74(3,24) N.S.

Group X Time 3 .67 ,4?(3,24) N.S.

231Item 9 - Orientation Animate— Visual and Auditory

This item assesses the infant's response to the presentation of examiner's face together with his face. Addicted infants (X - 3.60) stilled, focused on the stimulus when presented and made brief follow­

ing; nonaddicted infants (X = 5.75) focused and followed for more than

a 30° arc, made smooth movements; they occasionally lost the stimulus,

but were able to find it again. See Table 24 for a summary of these

data.

TABLE 24SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON ITEM 9—

ORIENTATION ANIMATE— VISUAL AND AUDITORY

Source of Variation df MS F Significance

Group 1 46.22 12.62 (8) p<.01

Time 3 3.23 1,92(3,24) P <.01Group X Time 3 .43 *25(3,24) p<.01

232Item 20 - Activity (Alert States)

This is a summary score of spontaneous and elicited activity of the infant, scored on a scale of 0-3 and converted to scores 1 through 9. A score of 0 indicates that the infant engaged in no activity; a

score of 3 indicates that the infant engaged in much activity. The

sums assigned to spontaneous and elicited activities are summed. For example, a total score of 2 receives a Brazelton score point of 3.

Addicted infants (X = 6.13) earned scores that summed to 5, which means

they engaged in activity within a range between moderate and much

activity; nonaddicted infants (X ® 4.10) earned scores that summed to 3, which means that they were less active during the examining periods. See Table 25 for a summary.

TABLE 25

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON ITEM 20— ACTIVITY (ALERT STATES)

Source of Variation df MS F Significance

Group 1 21.02 COw00• p<.05

Time 3 49.17 ,41<3,24) N.S.Group X Time 3 .69 ■58<3,24) N.S.

233Item 26 - Hand to Mouth Facility (All States)

This item represents the extent to which an infant brings his

hands to his mouth in order to aid in self-quieting behavior. Addicted

infants (X ® 4.10) typically brought their hands to the mouth area«•twice, but made no insertion; nonaddicted infants (X « 6.00) made one

brief insertion but were unable to maintain it. Table 26 contains the summary of results.

TABLE 26

SUMMARY OF RESULTS OF ANALYSIS OF VARIANCE WITH BRAZELTON ITEM 26— HAND TO MOUTH FACILITY

Source of Variation df MS F Significance

Group 1 36.10 9.53 P <.05Time 3 6.10 2.43 N.S.

Group X Time 3 .70 .28 N.S.

APPENDIX XVIITABLE 27 a) SUMMARY OF SIGNIFICANTLY DIFFERENT GROUP MEANS

ON THOSE ITEMS WHERE TIME WAS SIGNIFICANT AS A MAIN EFFECT— NO INTERACTION SIGNIFICANCE

TABLE 27 b) SUMMARY OF SIGNIFICANTLY DIFFERENT TIME MEANS FOR THOSE ANALYSES OF VARIANCE WHERE GROUP AND TIME

WERE SIGNIFICANT AS MAIN EFFECTS— NO INTERACTION SIGNIFICANCE

234

235

TABLE 27aSUMMARY OF SIGNIFICANTLY DIFFERENT GROUP MEANS ON THOSE ITEMS WHERE

TIME WAS SIGNIFICANT AS A MAIN EFFECT— NO INTERACTION SIGNIFICANCE

Items Addicted Infants Nonaddicted Infants Significance

5 2.50 5.15 p<.018 3.90 5.80 p<.0510 3.25 5.25 P < *0512 3.45 4.85 p < .0525 4.05 6.70 p<.001

TABLE 27b

SUMMARY OF SIGNIFICANTLY DIFFERENT TIME MEANS FOR THOSE ANALYSES OF VARIANCE ON ITEMS WHERE GROUP AND TIME WERE SIGNIFICANT AS

MAIN EFFECTS— NO INTERACTION SIGNIFICANCE

Item 5

13.0

23.5

33.7

*4

5.1

Item 25

* p <.05** p <.01

4.7 4.8 5.3 6.7|

. *

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