Introduction:

Dr. Vele-Tabaddor

Based on extensive developmental evidence, professionals have begun to regard parent-infant interaction as an important context through which to influence children's long-term developmental trajectories (Shonkoff & Phillips, 2000; National Scientific Council on the Developing Child, 2004; Zigler, Finn Stevenson & Hall, 2002). Addressing infant-parent interaction patterns within the context of early intervention has potential long-term implications for both child and family development (Brooks-Gunn, Berlin, & Fugligni, 2000; Ramey, Campbell, & Ramey, 1999). Early, secure attachments contribute to the development of a broad range of competencies in children, including love of learning, positive self-esteem, positive social skills, successful relationships, sophisticated social-emotional skills, and stronger cognitive abilities (Davies & Forman, 2002; Dawson & Ashman, 2000; Kochanska, 2002; Lerner & Castellino, 2002; Trevarthen, 2001)

Evaluations of relationship-based, dyadic interventions that target the caregiver-child relationship have shown relative success (van IJzendoorn, Juffer, Duyvestyan, 1995, Heinecke, Goorsky, Moscov, Dudley & Gordon, et al., 2000; McDonough, 2004). Relationship-based, dyadic approaches focus on supporting nurturing caregiver-child relationships for the purpose of strengthening attachment relationships between parents and children. Such approaches have been shown to particularly scaffold parent's capacity to provide responsive and sensitive parenting (Berkule, 2007; Heinecke, Goorsky, Moscov, Dudley & Gordon, et al., 2000; van Zeijl, Mesman, Van IJzendoorn, Bakermans-Kranenburg, Juffer, et al., 2006).

Relationship-based, dyadic interventions can include behavioral approaches that focus on preventive measures (e.g., parent education, modeling and support) (Lyons-Ruth, Connell, Grunebaum, & Botein, 1990; Kim, & Mahoney, 2005; Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003, Peterson, Luze, Eshbaugh, 2007), therapeutic approaches (e.g., reflective practice, interactive coaching and discussion) (Gowen & Nebrig, 2002; Mendelsohn, Valdez, Flynn, Foley, Berkule, et al., 2007; McDonough, 2004; van Doesum, Hosman, & Riksen-Walraven, 2005; Magill-Evans, Harrison, Benzies, Gierl, & Kimak, 2007) and/or a combination of the two approaches (Brazelton, 1994; 1998; 1999; Bakersman-Kranenburg, Juffer, van IJzendoorn, 1998; Malik, 2005). Recently, it has been demonstrated that benefits to children and families accrue when a combination of both behavioral and therapeutic approaches are used (Bakersman-Kranenburg, Juffer, van IJzendoorn, 1998; Malik, 2005; Together, these approaches offer collaborative and reflective strategies for professionals so that they can orient families to their child's cues and offer strategies for better interaction and responsiveness. Yet, despite their success, there remains limited evidence of the effectiveness of individualized, combined behavioral-therapeutic approaches with diverse populations (e.g., Latino, low SES mother-infant dyads), and what, if any are the direct effects of integrating therapeutic approaches in large-scale, behavioral programs targeting "high-risk" families such as Early Head Start (EHS).

In this pilot study we compared the effects of the following two types of relationship-based intervention for families on maternal responsiveness: (1) relationship-based model implemented in Early Head Start with additional therapeutic videotape analysis intervention and (2) relationship-based Early Head Start without the additional therapeutic videotape analysis intervention. It was hypothesized that the intervention group of mothers who will receive the additional therapeutic intervention would be more responsive to infant cues and distress, more scaffolding of infant language and communication, and less intrusive and negative than comparison mothers from the same EHS program who did not receive the therapeutic videotape analysis intervention.

Methods:

Sample & Design
Fifteen Latino mothers and their children who enrolled in an urban EHS program participated in this study (7 boys, 8 girls). At the time of enrollment in the EHS Program, these mothers also agreed to participate in a large-scale evaluation research project that was implemented by a partnership between the local EHS program and university-based researchers.

The larger evaluation study included a baseline research assessment that was repeated 10-month post enrollment. At baseline, (i.e. enrollment in EHS), infants ranged in age from 5-19 months (M = 7.27, SD = 3.47). At the 10-month follow-up assessment, infants ranged in age from 11-29 months (M = 16.07, SD = 2.52). All the children who participated in the evaluation were healthy and normally developing. Their developmental status was established by developmental psychologists who tested children individually with the Bayley Scales of Infant Development II (Bayley, 1993). The average Mental Development Index score at enrollment was M = 89.71, SD = 3.12, and scores ranged from 81-95.

Mothers ages ranged from 21-36 years (M = 28.21, SD = 5.10). All mothers were of Latino origin (Dominican = 33.3%, Mexican = 20.0%, Puerto Rican = 20.0% and South American = 26.7%) and spoke Spanish (91%). Most mothers were married (68%), had completed high school or more (57.7%), and were not employed outside of the home (84.3%). To meet federal program requirements for EHS, over 90% of program participants were low income as defined by federal poverty guidelines (e.g., less than 16,480 for a family of four, based on all sources of cash income including child support and alimony). Most families (95%) received some sort of public assistance such as Medicaid, food stamps, and WIC.

All mothers who agreed to be in the larger evaluation study were approached by the first author about additional participation in the videotape analysis intervention, with the exception of mothers who did not have any proficiency in English. Seven mothers agreed to participate in the additional intervention during the first 10-months of their participation in the EHS program and the evaluation research protocol. For the purpose of this pilot study, the seven mothers who agreed to participate in the videotape analysis intervention were matched based on child gender and age to 8 randomly selected mothers and infants who were enrolled in the larger local evaluation study. There were not demographic differences between the mothers and infants who participated in the videotape analysis and the matched comparison group (see Table 1).

Table 1
Participant Demographics

Intervention
a) Relationship-based Early Head Start: EHS services were based on an individualized, relationship-based, dyadic approach that focused on parenting and child development education. Mothers and infants who participated in this EHS program attended 2 weekly center-based classes. In addition support workers visited families in their homes twice a month. The focus of center-based classes was to strengthen the bond between the mother and her infant through learning activities. Center-based classes provided an environment in which mothers could attend to their children without distractions. Home visits provided an individualized, educational link to classroom activities and allowed the same staff member (i.e. lead teacher) to facilitate the bonding process by encouraging further interactions between caregivers and their children during daily activities like feeding or bathing.

b) Videotape Analysis Intervention: McDonough's (2004) Interaction Guidance approach was adapted in this study for EHS mothers of low-income and multiply-stressed environments. EHS mothers met with a therapist for five individual therapy sessions over the first 10 months of participation in EHS. During each session the therapist and the mother observed a videotaped play interaction of the mother and her child that was recorded just prior to enrollment in the local EHS program. At each meeting the same videotape session was observed and each time a specific area of child development was addressed including: language and problem solving, play, and social-emotional development. During each session, the therapist asked mothers to reflect on their child's behaviors and their own for each of the areas of development covered; by way of self-discovery, possibilities for scaffolding were discussed. The therapist refrained from didactic teaching and instead, asked mothers leading questions and reinforced positive behaviors. The experience was intended to empower mothers and support their own discovery of what behaviors were most successful with their children. The approach was not intrusive, demanding or proscriptive. At each session, relevant written materials were also provided for further child development education.

Measures
Mother-infant interactions were videotaped during 10-minute episodes of play in a separate room at the EHS program. Mothers were instructed to sit next to their child on the floor and play with their child as they normally would. These play sessions occurred just prior to enrollment in the EHS program and again 10-months post enrollment. Maternal responsiveness to child's play, language and social-emotional cues was coded for the entire 10-minutes of play of each session Responsiveness was defined as mothers' actions that were contingent on communication from the child and were appropriate to the needs and desires of the child (Bornstein & Tamis-LeMonda, 1997; van den Boom & Hoeksma, 1997).

Specifically, 11 dimensions of maternal responsiveness were coded including:, positive touch, leading touch, positive tone, negative tone, emotional responsiveness, behavioral responsiveness, directiveness, participatory activity, language frequency, teaching achievement, sophistication of play (see Appendix 1 for definitions of each dimension). A 4-point scale (0-3) was used to score each category of the three domains of maternal responsiveness. A higher score suggested more maternal responsiveness and a lower score less responsiveness. This coding scheme was based on aspects of maternal interaction behaviors that have been referred to in the literature (Kochanksa, 1997; Mahoney, Powell, & Finger, 1986; Meadow-Orlans & Steinberg, 1993; Bornstein & Tamis-LeMonda, 1997) and adapted to the Hispanic population of this study (Mahoney et al., 1986; Meadow-Orlans & Steinberg, 1993).

In practice coding of similar videotapes collected from participants in the larger evaluation, 3 experienced coders reached 90% agreement before coding the videotapes of the current sample. Reliability between coders was assessed by calculating Pearson correlations between coders 1 and 2 and coders 1 and 3 for each of the 11 dimensions coded and by calculating. At baseline, correlations between coders 1 and 2 ranged from .34 to .89. At outcome, correlations between coder 1 and coder 3 ranged from .54 to .95.

Analysis
To reduce the number of dependent measures, a principal components Factor analysis with Varimax rotation was conducted. Three variables-positive touch, negative tone and play sophistication were highly skewed given the majority of cases scored zero. These variables were omitted from analysis.

Three factors were extracted from analyses, accounting for 74.01% of the variance at baseline and 75.07% of the variance at outcome. Analysis of eigen values of obtained factors (with the usual criterion of 1 as a minimum), suggested a 3-component solution. The first component: Didactic Stimulation, explaining 28.98 % of the variance of the variables at baseline and 30.84 % at outcome, consisted of three variables: participatory activity, teaching achievement, and language frequency. The second factor: Directiveness, explaining 24.77 % of the variance at baseline and 23.71 % at outcome, consisted of behavioral responsiveness, directiveness, and leading touch. The third component: Expressive Affectivity, explaining 20.27 % of the variance at baseline and 20.52 % at outcome, consisted of emotional responsiveness and positive tone. The factor loadings are presented in Table 2 (Principal Component Analysis of Mother-Child Interaction Variables).

Table 2
Principal Component Analysis of Mother-Child Interaction Variables

Results:
As expected, Mann-Whitney U tests did not show any significant differences between the experimental and comparison group at baseline; mothers in both of these groups demonstrated similar levels of Didactic Stimulation (U = 20.50, NS), Directiveness (U = 23.00, NS) and Expressive Affectivity (U = 20.00, NS) before participating in any intervention. Ten months later, tests showed that mothers in the experimental group showed significantly more didactic stimulation (U = 1.00, p < .05) and affective expressivity (U = 9.50, p = .05) compared to before intervention. The matched comparison group also showed trends for more didactic stimulation and affective expressivity post intervention, but not at the level of change as the participants who received the additional, therapeutic intervention. (See Table 2).

Table 2
Descriptive Statistics for Mother-Child Interaction Factors within Video Analysis Intervention and Comparison Group over Time

Furthermore, between group analyses showed the experimental group who participated in therapeutic-based, videotape analysis intervention and relationship Ðbased dyadic EHS services demonstrated more Didactic Stimulation (U = 3.00, p < .05), more Directiveness (U = 8.50, p < .05) and more Expressive Affectivity (U = 9.50, p < .05) than mothers who only participated in EHS across time.

Discussion:
Although results should be interpreted with caution, as only 15 total subjects were examined with non-parametric analyses, findings suggest that EHS mothers who participated in the additional therapeutic videotape analysis intervention showed more didactic stimulation, directiveness, and expressive affectivity after 10 months than did mothers who participated in the same Early Head Start program, but did not participate in the videotape analysis intervention.

After participating in videotape analysis intervention, EHS mothers were more emotionally responsive, more participatory, used more language, teaching strategies and sophisticated play styles during toy play interactions with their children than did other EHS mothers who did not engage in the additional intervention. Results suggest that a combined approach of behavioral and therapeutic intervention is more successful short-term in improving maternal responsiveness among high-risk families than is EHS intervention alone.

Combining approaches improves maternal responsiveness because of the unique strength-based, reflective, collaborative elements embedded in videotape analysis intervention and the developmental education and supportive family services offered by EHS. The additional videotape analysis intervention not only gives mothers the opportunity to discover the needs of their child, but more importantly encourages them to share their thoughts and concerns about their child in a way that is empowering and reinforcing of their caregiving expertise. Moreover, when families first enroll in EHS, there is a period of transition involving the establishment of new relationships and partnerships with staff and other EHS families. For many, this period of transition can be overwhelming and derail full participation in the program, undermining program education. By design, videotape analysis intervention enables mothers to meet with a therapist in a private setting, creating the opportunity for relationship building with a single provider. Feeling at ease, mothers may find it easy to transition more comfortably into the program, participate in services and welcome provider input.

Findings from this study have implications for early prevention and intervention efforts working with "at-risk" families. In this study, a more therapeutic-based approach improved sensitive parenting among EHS mothers beyond the effects of a behavioral-dyadic approach. It would be worthwhile to further examine the types of program parameters effective in strengthening nurturing parenting and whether more individualized, therapeutic approaches like videotape analysis intervention could be integrated into behaviorally focused programs to strengthen parent-child relationships.

Appendix 1.
Definitions of Dimensions of Maternal Responsiveness

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